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Perception of picky eating among children in Singapore and its impact on caregivers: a questionnaire survey

Perception of picky eating among children in Singapore and its impact on caregivers: a... Background: Picky eating is relatively common among infants and children, often causing anxiety for parents and caregivers. The purpose of this study was to determine the key aspects of picky eating and feeding difficulties among children aged 1 to 10 years in Singapore and the impact on their parents or caregivers. Methods: In this survey, 407 parents or grandparents who are the primary caregivers of children aged 1 to 10 years in Singapore were interviewed via telephone using a structured questionnaire of 36 questions. Respondents were randomly selected from the Singapore Residential Telephone Directory to meet a pre-set interlocked quota of race, sex, and age to represent the population. Quantitative data collected included demographics, body weight and height, respondents’ perceptions of the duration of picky eating, the child’s eating habits and perceived health status, respondents’ attitudes towards picky eating, coping strategies and the impact on family relationships. Bonferroni z-test and t-test were used to indicate significance across groups or demographics, while Pearson correlation coefficient was used to measure the strength of association between variables. Results: One-half of the respondents reported that the child was ‘all the time’ (25.1%) or sometimes (24.1%) a picky eater. When aided with a list of typical behaviours, the respondent-reported prevalence of picky eating or feeding difficulties occurring ‘all the time’ increased to 49.6%. The highest number of respondents first noticed the child’s picky eating behaviours or feeding difficulties as early as 1 year (20.0%). Children 3 to 10 years [p = 0.022], children of professional respondents (p = 0.019), and children with a family history of picky eating (p = 0.03) were significantly more likely to be picky eaters. Overall, all ‘picky eating’ and all ‘feeding difficulty’ behaviours occurring ‘all the time’ were significantly associated with caregiver stress when feeding (p = 0.000026 and p = 0.000055, respectively) and with a negative impact on family relationships (p = 0.011 and p = 0.00000012, respectively). Conclusions: The perceived prevalence and duration of picky eating behaviours and feeding difficulties are high. The impact on the respondent and family relationships appears to be significant in Singapore. Parental concerns about picky eating should be adequately assessed and managed in routine clinic consultations. Keywords: Child, Child preschool, Family health, Feeding behaviour, Singapore * Correspondence: paegohyt@nus.edu.sg Department of Paediatrics, Head & Senior Consultant, Division of Paediatric Pulmonary & Sleep, University Children’s Medical Institute, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074, Singapore Department of of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore Full list of author information is available at the end of the article © 2012 Goh and Jacob; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Goh and Jacob Asia Pacific Family Medicine 2012, 11:5 Page 2 of 8 http://www.apfmj.com/content/11/1/5 Background such as anorexia, gastro-oesophageal reflux disease, Picky eating is relatively common among infants and oesophagitis, food allergies and lactose intolerance. children [1], often causing anxiety for parents and care- givers [2,3]. Picky eating is, however, not clearly defined; Design the term ‘picky eating’ has been described as consump- In this questionnaire survey administered by telephone, tion of an inadequate variety of foods [3]. The ICD-10 parents or grandparents of children aged 1 to 10 years in describes ‘feeding disorder of infancy and childhood’, Singapore were interviewed between 12 May and 16 encompassing ‘difficulty (in) feeding’, as generally involv- June 2010 by trained interviewers. Respondents were ing food refusal and extreme faddiness in the presence randomly selected from the Singapore Residential Tele- of an adequate food supply, a reasonably competent phone Directory. The sample satisfied a pre-set inter- caregiver, and the absence of organic disease (F98.2) [4]. locked quota of race, sex, and age to closely reflect the Picky eating behaviours include rejection of certain demographics of Singapore children aged 1 to 10 years. types of food, acceptance of only certain foods, unwill- 407 respondents were interviewed by telephone and ingness to try new foods (food neophobia), limited in- completed a structured questionnaire. Topics included take of some food groups and strong food preferences demographic data, body weight and height, respondents’ [5]. Picky eating in early childhood can be related to eat- perceptions of the duration of picky eating, the child’s ing disorders in adolescence and early adulthood [6], eating habits and perceived health status, respondents’ and can occur in normally developing children as well as attitudes towards picky eating, coping strategies and the in those with medical or developmental disorders [7]. impact on family relationships. Behavioural feeding disorders may be associated with The interview took approximately 15 to 20 minutes to suboptimal development [8], and some children with complete 36 questions. The questionnaire consisted of food refusal and picky eating have poor weight gain [3]. mostly closed ended categorical questions with listed Importantly, parent’s perceptions of a child’s weight and options for the respondents to choose from (Additional eating habits may affect a child’s development and future file 1: Appendix). The main questions measured the be- lifestyle [9]. haviour, attitudes and perceptions of the respondents on The prevalence of picky eating is difficult to ascertain, picky eating and child feeding practices. A rating scale of but has been reported to be as high as 50% in children 1 to 4 was used, where 1 = never, 2 = rarely, 3 = sometimes aged 19 to 24 months in a study from the USA [10]. Be- and 4 = all the time. Other categorical questions, for ex- tween 20% and 60% of parents state that their young ample “Do you think your child is a picky eater?”, were children are not eating optimally [8]. answered by ‘yes’, ‘no’, ‘sometimes’ or ‘in the past’. Only 6 There is little information on picky eating and feeding questions were open-ended numeric questions covering difficulty in Asia. Therefore, this study was performed to the estimated height and weight of the child, the age of determine the key aspects of picky eating and feeding onset and duration of picky eating behavour and the difficulties among children aged 1 to 10 years in Singa- number of meals and snacks taken per day. As the survey pore and the impact on caregivers. was quantitative, no detailed discussions were conducted. A positive response of ‘all the time’ to any of the ques- Methods tions on picky eating behaviours qualified as picky eat- Specific objectives were to determine the local perceived ing. A positive response of ‘all the time’ to any of the prevalence of picky eating/feeding difficulties; parents’ questions on feeding difficulty behaviours qualified as and caregivers’ understanding of feeding difficulties; how feeding difficulty. parents and caregivers handle feeding difficulties; factors A series of statements relating to caregiver stress when that influence feeding difficulties; and impact of feeding feeding the child were asked and the respondents were difficulties on the children and family relationships. requested to rate the degree of agreement based on a 5- In this study, picky eating was characterised by fussi- point rating scale. Respondents rating the statement ness about eating certain foods and fussy meal time ‘agree’ or ‘strongly agree’ were considered to be experi- behaviours, while feeding difficulty was characterised by encing stress. sensory food aversion, fear of eating and insufficient intake. Statistical analysis The margin of error calculated at the 95% confidence Participants level for the sample size of 407 was 4.86% using the for- Inclusion criteria were a parent with a child aged 1 to mula: 10 years or a grandparent who was the primary caregiver of a child aged 1 to 10 years. Exclusion criteria were error ¼ 1:96  √ðÞ p1ðÞ  p =n chronic illnesses that impacted the child’s eating habits Goh and Jacob Asia Pacific Family Medicine 2012, 11:5 Page 3 of 8 http://www.apfmj.com/content/11/1/5 significant (p = 0.546), slightly more Chinese respondents where p is the observed percentage and n is the sample (27.5%) felt that the child was a picky eater than did size. For comparing proportions, Bonferroni z-test and t- Malay (20.6%) or Indian respondents (20.8%). test were used to indicate significance across groups or Breakdown by age showed that the 3 to 5 years and 6 demographics, while Pearson correlation coefficient was to 10 years age groups were significantly more com- used to measure the strength of association between monly reported as picky eaters (29.9% and 25.0%, re- variables. spectively) than were the 1 to 2 years age group (20.3%) [p = 0.022]. In addition, children of respondents who Results were professionals (34.2%) were significantly more likely Respondents’ and Children’s characteristics to be perceived as picky eaters than respondents from The respondents were most frequently the child’s other occupations (16.3% to 30.0%) [p = 0.019], as were mother (67.3%), followed by the father or grandmother, children with a family history of picky eating (36.5%) with 83.0% of the respondents being women (Table 1). when compared with children from families without a The most common occupation was homemaker (37.6%), picky eating history (19.5%) [p = 0.030]. followed by professionals and other white-collar workers. The highest number of respondents first noticed the Most respondents were educated to secondary (37.3%) child’s picky eating behaviours or feeding difficulties or tertiary (47.5%) levels. as early as 1 year (20.0%), with age having an almost lin- Among the children, 53.8% were boys and 46.2% were ear correlation with first showing of these behaviours girls. The age groups surveyed were 1 to 2 years, 3 to (Figure 1). Overall, the mean duration of picky eating 5 years and 6 to 10 years, with a similar number of chil- was reported to be 0.6 years in a 1-year-old child, dren in each age group (Table 1). The children were pre- 1.1 years in a 3-year-old, 3.0 years in a 6-year-old and dominantly Chinese (64.4%). The child’s primary carer 4.8 years in a 10-year-old (Figure 2). was usually a parent or grandparent (78.4%). When the typical ‘picky eating’ and ‘feeding difficulty’ behaviours were explored by item, the prevalences of Perceived prevalence of picky eating picky eating and feeding difficulties occurring ‘all the Almost one-half of the respondents spontaneously time’ were 47.4% and 15.2%, respectively, while the reported that the child was always (25.1%) or sometimes prevalence of any of either behaviour was 49.6%; 13.0% (24.1%) a picky eater. Even though it was not statistically of children were reported to have both picky eating and feeding difficulties. Table 1 Demographic characteristics of respondents and The most common typical behaviours of a picky eater children among the group responding ‘always’ included eating Respondent profile (%) Child profile (%) slowly or holding food in the mouth (14.3%), refusing Relationship to child Sex food, particularly fruit and vegetables (14.0%), eating sweets and fatty foods instead of healthy foods (13.3%), Mother 67.3 Male 53.8 not liking to try new foods (12.0%), eating snacks instead Father 15.7 Female 46.2 of meals (11.1%) and accepting only a few types of food Grandmother 15.7 Age group (years) (12.0%). The prevalence of feeding difficulties occurring Grandfather 1.2 1-2 32.7 ‘always’ was reported as follows: not liking the texture of Occupation 3-5 32.9 certain foods (6.6%), eating very little food (9.6%) and PMEB 28.7 6-10 34.4 fear of certain foods due to a previous bad experience (4.4%). Other white collar 19.7 Race Blue collar 7.4 Chinese 64.4 Housewife 37.6 Malay 16.7 Perceived health status Unemployed 2.9 Indian/other 18.9 The respondents generally perceived the child’s height Other 3.7 and weight to be normal (63.6% and 75.2%, respectively). Only 7.8% and 13.3% of respondents felt that the child Education was very short or short, and underweight or of low None 2.0 weight, respectively. Only 2.5% of the respondents Primary 13.3 reported that the child was overweight. There was a sig- Secondary 37.3 nificant correlation for respondents’ perceptions of the Tertiary (polytechnic) 19.7 child’s weight and body mass index (BMI) when the BMI Tertiary (university) 27.8 was within the normal range (p = 0.031; Table 2), but there was no correlation between respondents’ PMEB = professionals, managers, executives and businessmen. Goh and Jacob Asia Pacific Family Medicine 2012, 11:5 Page 4 of 8 http://www.apfmj.com/content/11/1/5 Figure 1 Age at first presentation of picky eating (n = 370). perceptions of the child’s weight and BMI when the BMI child’s eating habits than a relative or ‘other’ caregiver was either low or high. (54.9% versus 30.1–50.0%). The most common concerns Overall, spontaneous report of picky eating was signifi- about the consequences of picky eating behaviours were cantly associated with the respondents’ perception that the child’s physical and mental development (83.3% and the child was not energetic and healthy (p = 0.048). 54.5%, respectively). When explored, only ‘not liking the texture of certain Children tended to eat a mean of 2.9 meals per day foods’ occurring ‘all the time’ when compared with (range, 1–6) and had a mean of 1.9 snacks per day ‘never’, ‘rarely’ and ‘sometimes’ was significantly asso- (range, 0–5). A significant negative correlation was ciated with the respondents’ perception of a decrease in observed between the number of meals and the number the child’s health and activity levels (p = 0.0001). Simi- of snacks eaten per day for all respondents (R = 0.01) larly, ‘fear of certain foods due to a bad experience’ and this was greater for those who spontaneously (p = 0.025) and ‘throwing tantrums at mealtimes’ reported that the child is a picky eater all or some of the (p = 0.019) were significantly associated with the care- time (R = 0.06). givers’ perception of an increase in the child’s level of Most respondents felt responsible for ensuring that sickness and tiredness. the child was eating the right types of food (89.2%), en- suring that the child did not have too many fatty foods, Attitudes and coping mechanisms sweets and junk foods (88.7%) and encouraging the child Nearly half of the respondents (45.5%) reported that they to eat with the family (89.9%). Most respondents person- were ‘very much concerned’ that the child was a picky ally made sure that the child had enough food at every eater and a further one-third (37.1%) were ‘slightly con- meal (94.6%) and pressured them to always eat all the cerned’ (Figure 3). Respondents who cared for the child food on the plate (86.2%). To ensure that the child themselves tended to be more concerned about the received sufficient nutrition, respondents tended to Figure 2 Mean duration of picky eating by age. Goh and Jacob Asia Pacific Family Medicine 2012, 11:5 Page 5 of 8 http://www.apfmj.com/content/11/1/5 Table 2 Correlation between respondents’ perception of eaters. Respondents who perceived the child to be picky their child’s weight and body mass index eaters tended to have a family history of picky eating Body mass index Correlation coefficient p Value (45.1%) [p = 0.030]. Most respondents enjoyed feeding the child (54.5%) <14 0.076 0.576 and felt relaxed at mealtimes (70.8%). Ten of the 12 14 to <19 0.180 0.031* picky eating behaviours occurring ‘all the time’ were sig- ≥19 −0.177 0.114 nificantly associated with respondents’ reports of stress *Significant correlation. during feeding; 9 of the 12 picky eating behaviours oc- curring ‘all the time’ were significantly associated with a ensure the meals included vegetables, fruits and meats negative impact on family relationships. All 3 ‘feeding (62.7%), watch what the child eats (46.4%), plan or difficulty’ behaviours occurring ‘all the time’ were signifi- supervise the child’s meal (41.8%) and give the child milk cantly associated both with reports of stress in the care- from a bottle (40.0%). givers when feeding and with family relationships being The respondents used a variety of coping strategies affected (Table 4). (‘all the time’ and ‘sometimes’), including modifying the texture to make food easy to eat (65.6%), allowing televi- Discussion sion viewing at mealtimes (62.4%) and presenting food This study attempts to provide an overview of picky eat- in an age-appropriate manner (use of coloured cups or ing and feeding difficulties among children aged 1 to bottles; 52.8%). 10 years in Singapore and the impact on the children’s Certain attitudes and perceptions of parents or grand- parents or caregivers. The study was conducted as a parents of children with feeding difficulties were signifi- questionnaire survey among a representative sample of cantly associated with the reported persistent prevalence the Singapore population. of feeding difficulties (Table 3). Of these, pressure to eat The spontaneous caregiver-reported prevalence of such as ‘raising the voice and threatening the child until picky eating in this study was 49.2%, which is similar to the food is finished’ (p = 0.000003) and ‘making the child that of 50% reported by Carruth et al in their cross- eat when not hungry’ (p = 0.001) were most positively sectional survey [10]. Other studies have found rates associated with persistent behaviour, while ‘deciding the ranging from 17% in China to 29% in Canada [11–14]. type and quantity of food’ for the child was negatively When exploring typical behaviours, 49.6% of respon- associated (p = 0.005). Of the coping strategies, persistent dents’ children exhibited at least one ‘picky eating’ or prevalence was significantly associated with ‘consulting a ‘feeding difficulty’ behaviour ‘all the time’. doctor about the child’s eating habits’ (p = 0.001), ‘allow- The most common behaviours occurring ‘all the time’ ing a maid/caregiver to feed the child’ (p = 0.015) and were eating slowly or holding food in the mouth; refus- ‘giving the child milk from a bottle’ (p = 0.002). ing food, particularly fruit and vegetables; eating sweets and fatty foods instead of healthy foods; food neophobia; Family history and relationships eating snacks instead of meals and accepting only a few Approximately one-third of respondents (31.0%) had types of food. Wright et al found that eating a limited other family members that they considered to be picky variety and preferring drinks to food were the most Figure 3 Respondents’ concerns about their child’s picky eating behaviour. Goh and Jacob Asia Pacific Family Medicine 2012, 11:5 Page 6 of 8 http://www.apfmj.com/content/11/1/5 Table 3 Association of respondents’ attitudes and perceptions of child feeding with reported prevalence of feeding difficulties Respondents’ attitudes and perceptions of child feeding (occurring ‘all Feeding difficulties occurring ‘all the time’ the time’ compared with ‘never’, ‘rarely’ and ‘sometimes’) p Value Percent Percent (95% confidence interval) decrease increase Pressure to eat I have to raise my voice and threaten my child until he/she finishes the food 0.000003 (0.12–0.42) 27.2 If my child says “I’m not hungry”, I try to get him/her to eat anyway 0.001 (0.04–0.27) 15.7 Responsibility I decide if my child is eating the right types and quantity of food 0.005 (−0.18– -0.03) 10.4 Coping strategy I consult a doctor about my child’s eating habits. 0.001 (0.06–0.44) 24.8 I let my maid or other caregiver feed my child. 0.015 (0.01–0.24) 12.4 My child drinks from a milk bottle. 0.002 (0.04–0.20) 11.6 prevalent problem behaviours [3], while Jacobi et al. that some of the respondents’ attitudes and perceptions reported that picky eaters ate fewer foods and were more towards child feeding (deciding what the child will eat, likely to avoid vegetables [5]. Mascola et al found that raising the voice, threatening the child and making the picky eaters were more likely to consume a limited var- child eat even when not hungry) were significantly asso- iety of foods, required food prepared in specific ways, ciated with the reported prevalence of ‘feeding difficulty’ expressed stronger likes and dislikes for food, and had behaviours. However, it is not clear whether the associa- tantrums when denied foods [2]. Interestingly, in this tions noted are the cause or the result of the mealtime study, respondents who reported that the child was not behaviours. a picky eater were more likely to report picky eating One-third of respondents had other family members behaviours of 'eating slowly' or 'eating sweets instead of who were picky eaters, and those who perceived the healthy foods' (occurring 'all the time' and 'sometimes'). child to be picky eaters tended to have a family history This possibly reflects greater cultural acceptance of these of picky eating. Most ‘picky eating’ and all ‘feeding diffi- picky eating behaviours as normal in Singapore, thus culty’ behaviours appear to be significantly associated overlooking potential consequences. with respondents’ stress when feeding the child and with Although some studies have shown that picky eating a negative impact on family relationships. does not affect health or weight gain [11,14], two studies The respondents used a variety of coping strategies, found that children with eating problems gained less including modifying the texture to make food easy to weight than children without eating problems [3,15]. eat, allowing television viewing at mealtimes and Reduced intakes of energy, carbohydrate, fat and protein presenting food in an age-appropriate manner (use have been found to be evident among children with of coloured cups or bottles). Other strategies cited picky eating and feeding difficulties [15,16], although involved consulting a doctor about the child’s eating most children with problem eating achieve normal habits, allowing a maid/caregiver to feed the child and growth [3]. There was no evidence that the children in giving the child milk in a bottle. Nearly one-third of this study were smaller than expected for their age, but respondents (29.2%) consulted a doctor about the prob- further study is needed to ascertain the impact of eating lem of picky eating/feeding difficulty. Thus, clinic visits problems on childhood development. provide an opportunity for clinicians to assess the prob- In this study, the older age groups were more likely to lem, provide support and guidance to parents, exclude be picky eaters. The mean duration of picky eating by any underlying pathology, and initiate appropriate age suggests that picky eating may be a persistent and management. chronic problem in childhood, as reported in the study by Mascola et al. [2]. Study limitations and future research recommendations Picky eating caused the respondents considerable con- While this study provides insight into the attitudes of cern with nearly half being ‘very much concerned’; the parents with children who are picky eaters in Singapore, concerns were predominantly about the child’s physical the study investigated their perceptions of picky eating and mental health. This is in agreement with the study and it’s impact on the child’s health and family relation- by Mascola et al that found that picky eating is of con- ships. All data were caregiver-reported, with no inde- siderable parental concern [2]. It is interesting to note pendent measurement of the children’s mealtime Goh and Jacob Asia Pacific Family Medicine 2012, 11:5 Page 7 of 8 http://www.apfmj.com/content/11/1/5 Table 4 Association of picky eating and feeding difficulty behaviours with feelings of stress and with a negative impact on family relationships I feel stressed and frustrated when feeding My family relationships are affected my child (selected ‘strongly agree’) because of the stress of feeding my child (selected ‘strongly agree’) Behaviour (occurring ‘all the time’ compared p Value Percent p Value Percent with ‘never’, ‘rarely’ and ‘sometimes’)) (95% confidence interval) increase (95% confidence interval) increase Picky eating behaviours Complain about what is served 0.001 24.2 0.000003 20.2 (0.0664–0.4176) (0.0491–0.3539) Refuse food especially vegetables/fruits 0.001 18.1 0.0001 12.9 (0.0576–0.3046) (0.0331–0.2256) Refuse food like meats 0.0004 18.3 0.003 11.9 (0.0339–0.3314) (0.0037–0.2333) Push, hide or throw food during mealtime 0.021 28.2 0.051 3.8 (0.0015–0.5635) (−0.1200–0.1955) Eats the same food for all the meals 0. 052 12.0 0.225 4.8 (0. 0029–0.0237) (−0.0285–0.1240) Accept only a few types of food 0.009 16.3 0.0332021 8.6 (0.0318–0.2938) (−0.0077–0.1799) Not like to try new food 0.059 11.6 0.021 8.6 (−0.0089–0.2417) (−0.0077–0.1799) Eat slowly or hold food in the mouth 0.0003 19.6 0.071 6.6 (0.0721– -0.3194) (−0.0147–0.1471) Eat sweets and fatty foods instead 0.009 15.6 0.00002 13.8 of healthy foods (0. 0317–0.2802) (0.0374–0.2392) Eat snacks instead of meals 0.0004 21.5 0.00003 14.7 (0.0728–0.3563) (0.0343–0.2605) Throw tantrums at mealtimes 0.000000001 46.8 0.0000001 17.2 (0.2686–0.6683) (0.0082–0.3353) Prefer drinks to food 0.005 15.6 0.0001 11.7 (0.0317–0.2802) (0.0205–0.2135) Feeding difficulty behaviours Not like the texture of certain foods 0.00002 32.3 0.0003 14.8 (0.1331–0.5137) (0.0006–0.2961) Fear certain foods due to a bad 0.001 31.6 0.00008 18.4 experience previously (0.0840–0.5479) (−0.0094– -0.3767) Eat very little 0.038 12.6 0.006 9.0 (−0.0153–0.2673) (−0.0166–0.1969) behaviours or caregivers’ stress. Further studies are children’s physical and mental development. Picky eat- needed to fully understand the regional and ethnic varia- ing behaviours caused the respondents much stress tions in attitudes and coping strategies, as well as the im- when feeding their children. One-third of parents con- pact on the child, caregiver and other family members. sult their doctor about their child’s eating behaviours; during clinical consultations, parental concerns about Conclusion picky eating should be adequately assessed and mana- Caregivers of children who are picky eaters or have ged. Clinicians can help to guide parents on the best feeding difficulty behaviours were concerned about approaches to achieving good nutrition for children who the consequences of picky eating behaviours on the are picky eaters. Goh and Jacob Asia Pacific Family Medicine 2012, 11:5 Page 8 of 8 http://www.apfmj.com/content/11/1/5 Additional file 9. Jaballas E, Clark-Ott D, Clasen C, Stolfi A, Urban M: Parents' perceptions of their children's weight, eating habits, and physical activities at home and at school. J Pediatr Health Care 2011, 25:294–301. Additional file 1: Appendix. Child Eating Habits Survey 2010. 10. Carruth BR, Ziegler PJ, Gordon A, Barr SI: Prevalence of picky eaters among infants and toddlers and their caregivers' decisions about offering a new food. J Am Diet Assoc 2004, 104(1 Suppl 1):57–64. Competing interests 11. McDermott BM, Mamun AA, Najman JM, Williams GM, O'Callaghan MJ, Bor Daniel YT Goh has no competing interests. Anna Jacob is an employee of W: Preschool children perceived by mothers as irregular eaters: physical Abbott Laboratories (Singapore) Pte Ltd. and psychosocial predictors from a birth cohort study. J Dev Behav This study was supported by an education grant from Abbott Nutrition, a Pediatr 2008, 29:197–205. division of Abbott Laboratories (Singapore) Pte Ltd. 12. Li Y, Shi A, Wan Y, Hotta M, Ushijima H: Child behavior problems: prevalence and correlates in rural minority areas of China. Pediatr Int Authors’ contributions 2001, 43:651–661. DG contributed the concept and design of study, analysis and data 13. Manikam R, Perman JA: Pediatric feeding disorders. J Clin Gastroenterol interpretation, revisions, review and approval of the manuscript. AJ 2000, 30:34–46. contributed the concept and design of study, data collection, compilation, 14. Rydell AM, Dahl M, Sundelin C: Characteristics of school children who are analysis and interpretation of data and preparation of the manuscript. Both choosy eaters. J Genet Psychol 1995, 156:217–229. authors read and approved the final manuscript. 15. Lindberg L, Ostberg M, Isacson IM, Dannaeus M: Feeding disorders related to nutrition. Acta Paediatr 2006, 95:425–429. Authors’ information 16. Dubois L, Farmer AP, Girard M, Peterson K: Preschool children's eating DG, MBBS(S'pore), MMed(Paeds), FRCPCH(UK), FCCP(USA), FAMS, is an behaviours are related to dietary adequacy and body weight. Eur J Clin Associate Professor and Head of the Department of Paediatrics, Head & Nutr 2007, 61:846–855. Senior Consultant, Division of Paediatric Pulmonary & Sleep, University Children’s Medical Institute, National University Hospital and Yong Loo Lin doi:10.1186/1447-056X-11-5 School of Medicine, National University of Singapore, Singapore. Cite this article as: Goh and Jacob: Perception of picky eating among AJ, MSc Nutrition and Dietetics, BSc Food Service Management and Dietetics, children in Singapore and its impact on caregivers: a questionnaire survey. Asia Pacific Family Medicine 2012 11:5. is Senior Manager of Nutrition Science and Communications, Abbott Nutrition International, Singapore. Acknowledgements This research was coordinated by Magdalena Pang, Abbott Laboratories (Singapore) Pte. Ltd. Andrew Lau and Jason Soriano, Media Research Consultants Pte Ltd, provided data collection and statistical analysis. We thank Mary Smith of Ping Healthcare Pte. Ltd. who provided medical writing services on behalf of the principal investigator, supported by an educational grant from Abbott Laboratories (Singapore) Pte Ltd. Author details Department of Paediatrics, Head & Senior Consultant, Division of Paediatric Pulmonary & Sleep, University Children’s Medical Institute, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074, Singapore. Department of of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore. Nutrition Science and Communications, Abbott Nutrition International, Singapore, Singapore. Received: 7 February 2012 Accepted: 22 June 2012 Published: 20 July 2012 References 1. 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Chatoor I, Ammaniti M: Classifying feeding disorders of infancy and early childhood.In Age and Gender Considerations in Psychiatric Diagnosis: a • No space constraints or color figure charges Research Agenda for DSM-V. Edited by Narrow WE, First MB, Sirovatka PJ, • Immediate publication on acceptance Regier DA. Arlington: American Psychiatric Association; 2007:227–242. • Inclusion in PubMed, CAS, Scopus and Google Scholar 7. Nicholls D, Bryant-Waugh R: Eating disorders of infancy and childhood: definition, symptomatology, epidemiology, and comorbidity. Child • Research which is freely available for redistribution Adolesc Psychiatr Clin N Am 2009, 18:17–30. 8. Kerzner B: Clinical investigation of feeding difficulties in young children: Submit your manuscript at a practical approach. Clin Pediatr (Phila) 2009, 48:960–965. www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

Perception of picky eating among children in Singapore and its impact on caregivers: a questionnaire survey

Asia Pacific Family Medicine , Volume 11 (1) – Jul 20, 2012

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Springer Journals
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Copyright © 2012 by Goh and Jacob; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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1447-056X
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10.1186/1447-056X-11-5
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22816553
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Abstract

Background: Picky eating is relatively common among infants and children, often causing anxiety for parents and caregivers. The purpose of this study was to determine the key aspects of picky eating and feeding difficulties among children aged 1 to 10 years in Singapore and the impact on their parents or caregivers. Methods: In this survey, 407 parents or grandparents who are the primary caregivers of children aged 1 to 10 years in Singapore were interviewed via telephone using a structured questionnaire of 36 questions. Respondents were randomly selected from the Singapore Residential Telephone Directory to meet a pre-set interlocked quota of race, sex, and age to represent the population. Quantitative data collected included demographics, body weight and height, respondents’ perceptions of the duration of picky eating, the child’s eating habits and perceived health status, respondents’ attitudes towards picky eating, coping strategies and the impact on family relationships. Bonferroni z-test and t-test were used to indicate significance across groups or demographics, while Pearson correlation coefficient was used to measure the strength of association between variables. Results: One-half of the respondents reported that the child was ‘all the time’ (25.1%) or sometimes (24.1%) a picky eater. When aided with a list of typical behaviours, the respondent-reported prevalence of picky eating or feeding difficulties occurring ‘all the time’ increased to 49.6%. The highest number of respondents first noticed the child’s picky eating behaviours or feeding difficulties as early as 1 year (20.0%). Children 3 to 10 years [p = 0.022], children of professional respondents (p = 0.019), and children with a family history of picky eating (p = 0.03) were significantly more likely to be picky eaters. Overall, all ‘picky eating’ and all ‘feeding difficulty’ behaviours occurring ‘all the time’ were significantly associated with caregiver stress when feeding (p = 0.000026 and p = 0.000055, respectively) and with a negative impact on family relationships (p = 0.011 and p = 0.00000012, respectively). Conclusions: The perceived prevalence and duration of picky eating behaviours and feeding difficulties are high. The impact on the respondent and family relationships appears to be significant in Singapore. Parental concerns about picky eating should be adequately assessed and managed in routine clinic consultations. Keywords: Child, Child preschool, Family health, Feeding behaviour, Singapore * Correspondence: paegohyt@nus.edu.sg Department of Paediatrics, Head & Senior Consultant, Division of Paediatric Pulmonary & Sleep, University Children’s Medical Institute, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074, Singapore Department of of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore Full list of author information is available at the end of the article © 2012 Goh and Jacob; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Goh and Jacob Asia Pacific Family Medicine 2012, 11:5 Page 2 of 8 http://www.apfmj.com/content/11/1/5 Background such as anorexia, gastro-oesophageal reflux disease, Picky eating is relatively common among infants and oesophagitis, food allergies and lactose intolerance. children [1], often causing anxiety for parents and care- givers [2,3]. Picky eating is, however, not clearly defined; Design the term ‘picky eating’ has been described as consump- In this questionnaire survey administered by telephone, tion of an inadequate variety of foods [3]. The ICD-10 parents or grandparents of children aged 1 to 10 years in describes ‘feeding disorder of infancy and childhood’, Singapore were interviewed between 12 May and 16 encompassing ‘difficulty (in) feeding’, as generally involv- June 2010 by trained interviewers. Respondents were ing food refusal and extreme faddiness in the presence randomly selected from the Singapore Residential Tele- of an adequate food supply, a reasonably competent phone Directory. The sample satisfied a pre-set inter- caregiver, and the absence of organic disease (F98.2) [4]. locked quota of race, sex, and age to closely reflect the Picky eating behaviours include rejection of certain demographics of Singapore children aged 1 to 10 years. types of food, acceptance of only certain foods, unwill- 407 respondents were interviewed by telephone and ingness to try new foods (food neophobia), limited in- completed a structured questionnaire. Topics included take of some food groups and strong food preferences demographic data, body weight and height, respondents’ [5]. Picky eating in early childhood can be related to eat- perceptions of the duration of picky eating, the child’s ing disorders in adolescence and early adulthood [6], eating habits and perceived health status, respondents’ and can occur in normally developing children as well as attitudes towards picky eating, coping strategies and the in those with medical or developmental disorders [7]. impact on family relationships. Behavioural feeding disorders may be associated with The interview took approximately 15 to 20 minutes to suboptimal development [8], and some children with complete 36 questions. The questionnaire consisted of food refusal and picky eating have poor weight gain [3]. mostly closed ended categorical questions with listed Importantly, parent’s perceptions of a child’s weight and options for the respondents to choose from (Additional eating habits may affect a child’s development and future file 1: Appendix). The main questions measured the be- lifestyle [9]. haviour, attitudes and perceptions of the respondents on The prevalence of picky eating is difficult to ascertain, picky eating and child feeding practices. A rating scale of but has been reported to be as high as 50% in children 1 to 4 was used, where 1 = never, 2 = rarely, 3 = sometimes aged 19 to 24 months in a study from the USA [10]. Be- and 4 = all the time. Other categorical questions, for ex- tween 20% and 60% of parents state that their young ample “Do you think your child is a picky eater?”, were children are not eating optimally [8]. answered by ‘yes’, ‘no’, ‘sometimes’ or ‘in the past’. Only 6 There is little information on picky eating and feeding questions were open-ended numeric questions covering difficulty in Asia. Therefore, this study was performed to the estimated height and weight of the child, the age of determine the key aspects of picky eating and feeding onset and duration of picky eating behavour and the difficulties among children aged 1 to 10 years in Singa- number of meals and snacks taken per day. As the survey pore and the impact on caregivers. was quantitative, no detailed discussions were conducted. A positive response of ‘all the time’ to any of the ques- Methods tions on picky eating behaviours qualified as picky eat- Specific objectives were to determine the local perceived ing. A positive response of ‘all the time’ to any of the prevalence of picky eating/feeding difficulties; parents’ questions on feeding difficulty behaviours qualified as and caregivers’ understanding of feeding difficulties; how feeding difficulty. parents and caregivers handle feeding difficulties; factors A series of statements relating to caregiver stress when that influence feeding difficulties; and impact of feeding feeding the child were asked and the respondents were difficulties on the children and family relationships. requested to rate the degree of agreement based on a 5- In this study, picky eating was characterised by fussi- point rating scale. Respondents rating the statement ness about eating certain foods and fussy meal time ‘agree’ or ‘strongly agree’ were considered to be experi- behaviours, while feeding difficulty was characterised by encing stress. sensory food aversion, fear of eating and insufficient intake. Statistical analysis The margin of error calculated at the 95% confidence Participants level for the sample size of 407 was 4.86% using the for- Inclusion criteria were a parent with a child aged 1 to mula: 10 years or a grandparent who was the primary caregiver of a child aged 1 to 10 years. Exclusion criteria were error ¼ 1:96  √ðÞ p1ðÞ  p =n chronic illnesses that impacted the child’s eating habits Goh and Jacob Asia Pacific Family Medicine 2012, 11:5 Page 3 of 8 http://www.apfmj.com/content/11/1/5 significant (p = 0.546), slightly more Chinese respondents where p is the observed percentage and n is the sample (27.5%) felt that the child was a picky eater than did size. For comparing proportions, Bonferroni z-test and t- Malay (20.6%) or Indian respondents (20.8%). test were used to indicate significance across groups or Breakdown by age showed that the 3 to 5 years and 6 demographics, while Pearson correlation coefficient was to 10 years age groups were significantly more com- used to measure the strength of association between monly reported as picky eaters (29.9% and 25.0%, re- variables. spectively) than were the 1 to 2 years age group (20.3%) [p = 0.022]. In addition, children of respondents who Results were professionals (34.2%) were significantly more likely Respondents’ and Children’s characteristics to be perceived as picky eaters than respondents from The respondents were most frequently the child’s other occupations (16.3% to 30.0%) [p = 0.019], as were mother (67.3%), followed by the father or grandmother, children with a family history of picky eating (36.5%) with 83.0% of the respondents being women (Table 1). when compared with children from families without a The most common occupation was homemaker (37.6%), picky eating history (19.5%) [p = 0.030]. followed by professionals and other white-collar workers. The highest number of respondents first noticed the Most respondents were educated to secondary (37.3%) child’s picky eating behaviours or feeding difficulties or tertiary (47.5%) levels. as early as 1 year (20.0%), with age having an almost lin- Among the children, 53.8% were boys and 46.2% were ear correlation with first showing of these behaviours girls. The age groups surveyed were 1 to 2 years, 3 to (Figure 1). Overall, the mean duration of picky eating 5 years and 6 to 10 years, with a similar number of chil- was reported to be 0.6 years in a 1-year-old child, dren in each age group (Table 1). The children were pre- 1.1 years in a 3-year-old, 3.0 years in a 6-year-old and dominantly Chinese (64.4%). The child’s primary carer 4.8 years in a 10-year-old (Figure 2). was usually a parent or grandparent (78.4%). When the typical ‘picky eating’ and ‘feeding difficulty’ behaviours were explored by item, the prevalences of Perceived prevalence of picky eating picky eating and feeding difficulties occurring ‘all the Almost one-half of the respondents spontaneously time’ were 47.4% and 15.2%, respectively, while the reported that the child was always (25.1%) or sometimes prevalence of any of either behaviour was 49.6%; 13.0% (24.1%) a picky eater. Even though it was not statistically of children were reported to have both picky eating and feeding difficulties. Table 1 Demographic characteristics of respondents and The most common typical behaviours of a picky eater children among the group responding ‘always’ included eating Respondent profile (%) Child profile (%) slowly or holding food in the mouth (14.3%), refusing Relationship to child Sex food, particularly fruit and vegetables (14.0%), eating sweets and fatty foods instead of healthy foods (13.3%), Mother 67.3 Male 53.8 not liking to try new foods (12.0%), eating snacks instead Father 15.7 Female 46.2 of meals (11.1%) and accepting only a few types of food Grandmother 15.7 Age group (years) (12.0%). The prevalence of feeding difficulties occurring Grandfather 1.2 1-2 32.7 ‘always’ was reported as follows: not liking the texture of Occupation 3-5 32.9 certain foods (6.6%), eating very little food (9.6%) and PMEB 28.7 6-10 34.4 fear of certain foods due to a previous bad experience (4.4%). Other white collar 19.7 Race Blue collar 7.4 Chinese 64.4 Housewife 37.6 Malay 16.7 Perceived health status Unemployed 2.9 Indian/other 18.9 The respondents generally perceived the child’s height Other 3.7 and weight to be normal (63.6% and 75.2%, respectively). Only 7.8% and 13.3% of respondents felt that the child Education was very short or short, and underweight or of low None 2.0 weight, respectively. Only 2.5% of the respondents Primary 13.3 reported that the child was overweight. There was a sig- Secondary 37.3 nificant correlation for respondents’ perceptions of the Tertiary (polytechnic) 19.7 child’s weight and body mass index (BMI) when the BMI Tertiary (university) 27.8 was within the normal range (p = 0.031; Table 2), but there was no correlation between respondents’ PMEB = professionals, managers, executives and businessmen. Goh and Jacob Asia Pacific Family Medicine 2012, 11:5 Page 4 of 8 http://www.apfmj.com/content/11/1/5 Figure 1 Age at first presentation of picky eating (n = 370). perceptions of the child’s weight and BMI when the BMI child’s eating habits than a relative or ‘other’ caregiver was either low or high. (54.9% versus 30.1–50.0%). The most common concerns Overall, spontaneous report of picky eating was signifi- about the consequences of picky eating behaviours were cantly associated with the respondents’ perception that the child’s physical and mental development (83.3% and the child was not energetic and healthy (p = 0.048). 54.5%, respectively). When explored, only ‘not liking the texture of certain Children tended to eat a mean of 2.9 meals per day foods’ occurring ‘all the time’ when compared with (range, 1–6) and had a mean of 1.9 snacks per day ‘never’, ‘rarely’ and ‘sometimes’ was significantly asso- (range, 0–5). A significant negative correlation was ciated with the respondents’ perception of a decrease in observed between the number of meals and the number the child’s health and activity levels (p = 0.0001). Simi- of snacks eaten per day for all respondents (R = 0.01) larly, ‘fear of certain foods due to a bad experience’ and this was greater for those who spontaneously (p = 0.025) and ‘throwing tantrums at mealtimes’ reported that the child is a picky eater all or some of the (p = 0.019) were significantly associated with the care- time (R = 0.06). givers’ perception of an increase in the child’s level of Most respondents felt responsible for ensuring that sickness and tiredness. the child was eating the right types of food (89.2%), en- suring that the child did not have too many fatty foods, Attitudes and coping mechanisms sweets and junk foods (88.7%) and encouraging the child Nearly half of the respondents (45.5%) reported that they to eat with the family (89.9%). Most respondents person- were ‘very much concerned’ that the child was a picky ally made sure that the child had enough food at every eater and a further one-third (37.1%) were ‘slightly con- meal (94.6%) and pressured them to always eat all the cerned’ (Figure 3). Respondents who cared for the child food on the plate (86.2%). To ensure that the child themselves tended to be more concerned about the received sufficient nutrition, respondents tended to Figure 2 Mean duration of picky eating by age. Goh and Jacob Asia Pacific Family Medicine 2012, 11:5 Page 5 of 8 http://www.apfmj.com/content/11/1/5 Table 2 Correlation between respondents’ perception of eaters. Respondents who perceived the child to be picky their child’s weight and body mass index eaters tended to have a family history of picky eating Body mass index Correlation coefficient p Value (45.1%) [p = 0.030]. Most respondents enjoyed feeding the child (54.5%) <14 0.076 0.576 and felt relaxed at mealtimes (70.8%). Ten of the 12 14 to <19 0.180 0.031* picky eating behaviours occurring ‘all the time’ were sig- ≥19 −0.177 0.114 nificantly associated with respondents’ reports of stress *Significant correlation. during feeding; 9 of the 12 picky eating behaviours oc- curring ‘all the time’ were significantly associated with a ensure the meals included vegetables, fruits and meats negative impact on family relationships. All 3 ‘feeding (62.7%), watch what the child eats (46.4%), plan or difficulty’ behaviours occurring ‘all the time’ were signifi- supervise the child’s meal (41.8%) and give the child milk cantly associated both with reports of stress in the care- from a bottle (40.0%). givers when feeding and with family relationships being The respondents used a variety of coping strategies affected (Table 4). (‘all the time’ and ‘sometimes’), including modifying the texture to make food easy to eat (65.6%), allowing televi- Discussion sion viewing at mealtimes (62.4%) and presenting food This study attempts to provide an overview of picky eat- in an age-appropriate manner (use of coloured cups or ing and feeding difficulties among children aged 1 to bottles; 52.8%). 10 years in Singapore and the impact on the children’s Certain attitudes and perceptions of parents or grand- parents or caregivers. The study was conducted as a parents of children with feeding difficulties were signifi- questionnaire survey among a representative sample of cantly associated with the reported persistent prevalence the Singapore population. of feeding difficulties (Table 3). Of these, pressure to eat The spontaneous caregiver-reported prevalence of such as ‘raising the voice and threatening the child until picky eating in this study was 49.2%, which is similar to the food is finished’ (p = 0.000003) and ‘making the child that of 50% reported by Carruth et al in their cross- eat when not hungry’ (p = 0.001) were most positively sectional survey [10]. Other studies have found rates associated with persistent behaviour, while ‘deciding the ranging from 17% in China to 29% in Canada [11–14]. type and quantity of food’ for the child was negatively When exploring typical behaviours, 49.6% of respon- associated (p = 0.005). Of the coping strategies, persistent dents’ children exhibited at least one ‘picky eating’ or prevalence was significantly associated with ‘consulting a ‘feeding difficulty’ behaviour ‘all the time’. doctor about the child’s eating habits’ (p = 0.001), ‘allow- The most common behaviours occurring ‘all the time’ ing a maid/caregiver to feed the child’ (p = 0.015) and were eating slowly or holding food in the mouth; refus- ‘giving the child milk from a bottle’ (p = 0.002). ing food, particularly fruit and vegetables; eating sweets and fatty foods instead of healthy foods; food neophobia; Family history and relationships eating snacks instead of meals and accepting only a few Approximately one-third of respondents (31.0%) had types of food. Wright et al found that eating a limited other family members that they considered to be picky variety and preferring drinks to food were the most Figure 3 Respondents’ concerns about their child’s picky eating behaviour. Goh and Jacob Asia Pacific Family Medicine 2012, 11:5 Page 6 of 8 http://www.apfmj.com/content/11/1/5 Table 3 Association of respondents’ attitudes and perceptions of child feeding with reported prevalence of feeding difficulties Respondents’ attitudes and perceptions of child feeding (occurring ‘all Feeding difficulties occurring ‘all the time’ the time’ compared with ‘never’, ‘rarely’ and ‘sometimes’) p Value Percent Percent (95% confidence interval) decrease increase Pressure to eat I have to raise my voice and threaten my child until he/she finishes the food 0.000003 (0.12–0.42) 27.2 If my child says “I’m not hungry”, I try to get him/her to eat anyway 0.001 (0.04–0.27) 15.7 Responsibility I decide if my child is eating the right types and quantity of food 0.005 (−0.18– -0.03) 10.4 Coping strategy I consult a doctor about my child’s eating habits. 0.001 (0.06–0.44) 24.8 I let my maid or other caregiver feed my child. 0.015 (0.01–0.24) 12.4 My child drinks from a milk bottle. 0.002 (0.04–0.20) 11.6 prevalent problem behaviours [3], while Jacobi et al. that some of the respondents’ attitudes and perceptions reported that picky eaters ate fewer foods and were more towards child feeding (deciding what the child will eat, likely to avoid vegetables [5]. Mascola et al found that raising the voice, threatening the child and making the picky eaters were more likely to consume a limited var- child eat even when not hungry) were significantly asso- iety of foods, required food prepared in specific ways, ciated with the reported prevalence of ‘feeding difficulty’ expressed stronger likes and dislikes for food, and had behaviours. However, it is not clear whether the associa- tantrums when denied foods [2]. Interestingly, in this tions noted are the cause or the result of the mealtime study, respondents who reported that the child was not behaviours. a picky eater were more likely to report picky eating One-third of respondents had other family members behaviours of 'eating slowly' or 'eating sweets instead of who were picky eaters, and those who perceived the healthy foods' (occurring 'all the time' and 'sometimes'). child to be picky eaters tended to have a family history This possibly reflects greater cultural acceptance of these of picky eating. Most ‘picky eating’ and all ‘feeding diffi- picky eating behaviours as normal in Singapore, thus culty’ behaviours appear to be significantly associated overlooking potential consequences. with respondents’ stress when feeding the child and with Although some studies have shown that picky eating a negative impact on family relationships. does not affect health or weight gain [11,14], two studies The respondents used a variety of coping strategies, found that children with eating problems gained less including modifying the texture to make food easy to weight than children without eating problems [3,15]. eat, allowing television viewing at mealtimes and Reduced intakes of energy, carbohydrate, fat and protein presenting food in an age-appropriate manner (use have been found to be evident among children with of coloured cups or bottles). Other strategies cited picky eating and feeding difficulties [15,16], although involved consulting a doctor about the child’s eating most children with problem eating achieve normal habits, allowing a maid/caregiver to feed the child and growth [3]. There was no evidence that the children in giving the child milk in a bottle. Nearly one-third of this study were smaller than expected for their age, but respondents (29.2%) consulted a doctor about the prob- further study is needed to ascertain the impact of eating lem of picky eating/feeding difficulty. Thus, clinic visits problems on childhood development. provide an opportunity for clinicians to assess the prob- In this study, the older age groups were more likely to lem, provide support and guidance to parents, exclude be picky eaters. The mean duration of picky eating by any underlying pathology, and initiate appropriate age suggests that picky eating may be a persistent and management. chronic problem in childhood, as reported in the study by Mascola et al. [2]. Study limitations and future research recommendations Picky eating caused the respondents considerable con- While this study provides insight into the attitudes of cern with nearly half being ‘very much concerned’; the parents with children who are picky eaters in Singapore, concerns were predominantly about the child’s physical the study investigated their perceptions of picky eating and mental health. This is in agreement with the study and it’s impact on the child’s health and family relation- by Mascola et al that found that picky eating is of con- ships. All data were caregiver-reported, with no inde- siderable parental concern [2]. It is interesting to note pendent measurement of the children’s mealtime Goh and Jacob Asia Pacific Family Medicine 2012, 11:5 Page 7 of 8 http://www.apfmj.com/content/11/1/5 Table 4 Association of picky eating and feeding difficulty behaviours with feelings of stress and with a negative impact on family relationships I feel stressed and frustrated when feeding My family relationships are affected my child (selected ‘strongly agree’) because of the stress of feeding my child (selected ‘strongly agree’) Behaviour (occurring ‘all the time’ compared p Value Percent p Value Percent with ‘never’, ‘rarely’ and ‘sometimes’)) (95% confidence interval) increase (95% confidence interval) increase Picky eating behaviours Complain about what is served 0.001 24.2 0.000003 20.2 (0.0664–0.4176) (0.0491–0.3539) Refuse food especially vegetables/fruits 0.001 18.1 0.0001 12.9 (0.0576–0.3046) (0.0331–0.2256) Refuse food like meats 0.0004 18.3 0.003 11.9 (0.0339–0.3314) (0.0037–0.2333) Push, hide or throw food during mealtime 0.021 28.2 0.051 3.8 (0.0015–0.5635) (−0.1200–0.1955) Eats the same food for all the meals 0. 052 12.0 0.225 4.8 (0. 0029–0.0237) (−0.0285–0.1240) Accept only a few types of food 0.009 16.3 0.0332021 8.6 (0.0318–0.2938) (−0.0077–0.1799) Not like to try new food 0.059 11.6 0.021 8.6 (−0.0089–0.2417) (−0.0077–0.1799) Eat slowly or hold food in the mouth 0.0003 19.6 0.071 6.6 (0.0721– -0.3194) (−0.0147–0.1471) Eat sweets and fatty foods instead 0.009 15.6 0.00002 13.8 of healthy foods (0. 0317–0.2802) (0.0374–0.2392) Eat snacks instead of meals 0.0004 21.5 0.00003 14.7 (0.0728–0.3563) (0.0343–0.2605) Throw tantrums at mealtimes 0.000000001 46.8 0.0000001 17.2 (0.2686–0.6683) (0.0082–0.3353) Prefer drinks to food 0.005 15.6 0.0001 11.7 (0.0317–0.2802) (0.0205–0.2135) Feeding difficulty behaviours Not like the texture of certain foods 0.00002 32.3 0.0003 14.8 (0.1331–0.5137) (0.0006–0.2961) Fear certain foods due to a bad 0.001 31.6 0.00008 18.4 experience previously (0.0840–0.5479) (−0.0094– -0.3767) Eat very little 0.038 12.6 0.006 9.0 (−0.0153–0.2673) (−0.0166–0.1969) behaviours or caregivers’ stress. Further studies are children’s physical and mental development. Picky eat- needed to fully understand the regional and ethnic varia- ing behaviours caused the respondents much stress tions in attitudes and coping strategies, as well as the im- when feeding their children. One-third of parents con- pact on the child, caregiver and other family members. sult their doctor about their child’s eating behaviours; during clinical consultations, parental concerns about Conclusion picky eating should be adequately assessed and mana- Caregivers of children who are picky eaters or have ged. Clinicians can help to guide parents on the best feeding difficulty behaviours were concerned about approaches to achieving good nutrition for children who the consequences of picky eating behaviours on the are picky eaters. Goh and Jacob Asia Pacific Family Medicine 2012, 11:5 Page 8 of 8 http://www.apfmj.com/content/11/1/5 Additional file 9. Jaballas E, Clark-Ott D, Clasen C, Stolfi A, Urban M: Parents' perceptions of their children's weight, eating habits, and physical activities at home and at school. J Pediatr Health Care 2011, 25:294–301. Additional file 1: Appendix. Child Eating Habits Survey 2010. 10. Carruth BR, Ziegler PJ, Gordon A, Barr SI: Prevalence of picky eaters among infants and toddlers and their caregivers' decisions about offering a new food. J Am Diet Assoc 2004, 104(1 Suppl 1):57–64. Competing interests 11. McDermott BM, Mamun AA, Najman JM, Williams GM, O'Callaghan MJ, Bor Daniel YT Goh has no competing interests. Anna Jacob is an employee of W: Preschool children perceived by mothers as irregular eaters: physical Abbott Laboratories (Singapore) Pte Ltd. and psychosocial predictors from a birth cohort study. J Dev Behav This study was supported by an education grant from Abbott Nutrition, a Pediatr 2008, 29:197–205. division of Abbott Laboratories (Singapore) Pte Ltd. 12. Li Y, Shi A, Wan Y, Hotta M, Ushijima H: Child behavior problems: prevalence and correlates in rural minority areas of China. Pediatr Int Authors’ contributions 2001, 43:651–661. DG contributed the concept and design of study, analysis and data 13. Manikam R, Perman JA: Pediatric feeding disorders. J Clin Gastroenterol interpretation, revisions, review and approval of the manuscript. AJ 2000, 30:34–46. contributed the concept and design of study, data collection, compilation, 14. Rydell AM, Dahl M, Sundelin C: Characteristics of school children who are analysis and interpretation of data and preparation of the manuscript. Both choosy eaters. J Genet Psychol 1995, 156:217–229. authors read and approved the final manuscript. 15. Lindberg L, Ostberg M, Isacson IM, Dannaeus M: Feeding disorders related to nutrition. Acta Paediatr 2006, 95:425–429. Authors’ information 16. Dubois L, Farmer AP, Girard M, Peterson K: Preschool children's eating DG, MBBS(S'pore), MMed(Paeds), FRCPCH(UK), FCCP(USA), FAMS, is an behaviours are related to dietary adequacy and body weight. Eur J Clin Associate Professor and Head of the Department of Paediatrics, Head & Nutr 2007, 61:846–855. Senior Consultant, Division of Paediatric Pulmonary & Sleep, University Children’s Medical Institute, National University Hospital and Yong Loo Lin doi:10.1186/1447-056X-11-5 School of Medicine, National University of Singapore, Singapore. Cite this article as: Goh and Jacob: Perception of picky eating among AJ, MSc Nutrition and Dietetics, BSc Food Service Management and Dietetics, children in Singapore and its impact on caregivers: a questionnaire survey. Asia Pacific Family Medicine 2012 11:5. is Senior Manager of Nutrition Science and Communications, Abbott Nutrition International, Singapore. Acknowledgements This research was coordinated by Magdalena Pang, Abbott Laboratories (Singapore) Pte. Ltd. Andrew Lau and Jason Soriano, Media Research Consultants Pte Ltd, provided data collection and statistical analysis. We thank Mary Smith of Ping Healthcare Pte. Ltd. who provided medical writing services on behalf of the principal investigator, supported by an educational grant from Abbott Laboratories (Singapore) Pte Ltd. Author details Department of Paediatrics, Head & Senior Consultant, Division of Paediatric Pulmonary & Sleep, University Children’s Medical Institute, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074, Singapore. Department of of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore. Nutrition Science and Communications, Abbott Nutrition International, Singapore, Singapore. Received: 7 February 2012 Accepted: 22 June 2012 Published: 20 July 2012 References 1. 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Asia Pacific Family MedicineSpringer Journals

Published: Jul 20, 2012

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