Nutrients

nutrients
Review
A Narrative Review of Childhood Picky Eating and
Its Relationship to Food Intakes, Nutritional Status,
and Growth
Tinu Mary Samuel 1 , Kathy Musa-Veloso 2 , Manki Ho 2 , Carolina Venditti 2 and
Yassaman Shahkhalili-Dulloo 1, *
1 Nestle Institute of Health Science, Nestle Research, Route du Jorat 57, Vers-chez-les-Blanc, 1000 Lausanne,
Switzerland; [email protected]
2 Intertek Health Sciences Inc., Food and Nutrition Group, 2233 Argentia Road, Suite 201, Mississauga,
ON L5N 2X7, Canada; [email protected] (K.M.-V.); [email protected] (M.H.);
[email protected] (C.V.)
* Correspondence: [email protected]; Tel.: +41-21-785-85-23

Received: 18 October 2018; Accepted: 10 December 2018; Published: 15 December 2018
Abstract: A main characteristic of children perceived as picky eaters is their tendency to avoid certain
foods or food groups. The goal of this narrative review is to provide an overview of published
studies that have examined whether picky eating in childhood is in fact associated with measurable
differences in food and/or nutrient intakes and growth. While picky eaters appear to consume less
vegetables compared to non-picky eaters, no consistent differences were observed for the intakes
of other food groups or the intakes of energy, macronutrients and dietary fiber. Although, in some
studies, picky eaters had lower intakes of certain vitamins and minerals, the levels consumed
generally exceeded the recommended values, suggesting nutritional requirements are being met.
No consistent relationship between childhood picky eating and growth status was observed, although
significant differences in body weight/growth between picky and non-picky eaters were most
discernible in studies where multiple defining criteria were used to identify picky eating. The research
area would benefit from the adoption of a uniform definition of picky eating. More longitudinal
assessments are also required to understand the long-term impact of picky eating on nutritional
status and growth.
Keywords: picky eating; food intake; diet; macronutrient; micronutrient; growth; children
1. Introduction
Picky eating, which is also referred to as fussy eating, selective eating, faddy eating, and
choosy eating, is a complex behavior that broadly refers to a combination of traits. As children
start complementary feeding and become exposed to an increasingly diversified diet, many begin to
exhibit “picky eating” behaviors. Currently, there is no concise definition for picky eating that has been
widely adopted in the literature. Instead, as noted by Jacobi et al. [1], picky eating has been described
as “more of an umbrella term for a spectrum of characteristics perceived by a caretaker or researcher”.
Some of the common behavioral traits that have been used to characterize picky eating include
food selectivity (i.e., avoiding the intake of certain foods or food groups), sensory-sensitivity (i.e.,
avoidance of a food based on its sensory properties, or requiring the preparation or presentation of
meals in a very particular way) and lack of interest in eating (i.e., eats only small amounts of food, has
a poor appetite, eats slowly) [1–8]. For instance, when asked to openly describe their child’s eating
behaviors, many parents of children perceived to be picky eaters reported that they tend to prefer
eating foods predominantly from one food group (e.g., “breads only” or “fruits only”), or to avoid
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Nutrients 2018, 10, 1992 2 of 30
certain food groups altogether (e.g., vegetables) [3,4,9]. Picky eaters may also eat only a limited number
of items from each food group (e.g., “eats only cereal or waffles from the bread group”, or “chicken
nuggets only from the meat group”, or “won’t eat any meat except turkey”) [3,4,9]. Additionally,
parents of picky eaters are more likely to report that their child does not consume an adequate amount
of food at each meal [4,8], or that the child does not eat the amount of food that the parent thinks they
should be eating [3,9]. In some cases, children who are viewed as picky eaters may also exhibit food
neophobia (i.e., an unwillingness to try new and unfamiliar foods) [3,4].
It is well recognized that a nutritionally-balanced diet is critical for ensuring normal growth
and development in children. Current dietary guidelines for children promote the intake of a varied
diet filled with healthy, nutrient-dense foods, comprising a wide range of vegetables and fruits,
cereals (preferably whole grains), lean proteins, and low-fat dairy products [10,11]. Foods that are
high in saturated fat, added sugars, and added salt, which could displace the intake of healthier
alternatives, should be limited [10,11]. These dietary recommendations help to ensure the adequate
intake of nutrients that are considered necessary for the proper growth and development of children.
The variety of foods consumed is also important, given that individual foods within each food group
can differ with respect to their nutritional profiles. For example, within the protein group, poultry
and meats provide rich sources of niacin and zinc, while seafoods are rich in omega-3 long-chain
polyunsaturated fatty acids, eicosapentaenoic acid and docosahexaenoic acid [10]. Meat, poultry and
seafoods are also sources of heme iron, which is more bioavailable than the non-heme iron present in
plant proteins [10].
Even though picky eating is often viewed as a common and normal part of a child’s growth and
development (i.e., from the time solid foods are introduced to early childhood), such selective eating
behaviors may lead to a limited intake of certain foods or food groups, and accordingly, of key nutrients.
In some children, it is possible that such disturbances in eating behaviors may result in a failure to
meet adequate nutritional and/or energy needs, which could have serious and negative implications
on health (e.g., growth impediment, nutritional deficiency, or other functional impairments). Indeed,
for a parent or caregiver, the picky eating behaviors of the child can be quite worrisome. It is important
to understand whether perceptions of picky eating are indeed associated with reduced diet variety
and nutrient intakes, and if these, in turn, have any implications on the child’s nutritional status
and growth.
Despite the lack of a “gold-standard” definition or tool available for identifying picky eaters,
many studies have been published in recent years on the subject. These include studies that assessed
whether picky eating, which is often perceived by the parent or caregiver based on their child’s
selective eating behaviors and limited food choices, is, in fact, consistently associated with measurable
differences in food intake.
In this narrative review, studies that assessed the food preferences and/or intakes of energy,
macronutrients, and micronutrients of children perceived as picky eaters (e.g., as collected through
food records), or measures of growth, are presented to better understand the nutritional and clinical
consequences of picky eating among children.
2. Methods
A search of the scientific literature was conducted to identify pertinent publications on picky eating
in children that were full-length peer-reviewed studies, published between 1 January 1950 and 31 July
2017. Eleven literature databases (Adis Clinical Trials Insight, Allied & Complementary Medicine™,
BIOSIS Previews® , CAB ABSTRACTS, Embase® , Foodline® : SCIENCE, FSTA® , Gale Group Health
Periodicals Database, Global Health, MEDLINE® , and NTIS: National Technical Information Service)
were searched using the electronic search tool ProQuest Dialog™. PubMed and Google Scholar were
also searched. The search terms were selected to broadly identify any publications related to picky
eating or its commonly used synonyms, such as food pickiness, fussy eating, finicky eating, choosy
eating, selective eating, food refusal, and faddy eating. Additionally, terms related to children (i.e.,
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infant, baby, toddler, children, boy, girl, teen, adolescent, youth, kid, preschool, youngster, or tot),
and variations of such terms, were used to stratify the publication search more fully. It should be noted
that subjects in each of the included studies were generally healthy (i.e., studies wherein the research
was conducted on subjects with a disease or medical condition for which secondary interventions
were required for feeding were not included in this review). Studies that involved children with
formally diagnosed eating disorders were also not included in this review. Over 3000 publication titles,
both quantitative and qualitative in nature, were screened for their relevance to this narrative review.
For the purposes of this review, a publication was deemed to be relevant for inclusion if it assessed
the relationship between picky eating and dietary intakes (i.e., intakes of foods/food groups, energy,
macronutrients, and/or micronutrients) or measures of growth in children. Only articles with full
texts available in English were considered in this review.
The information that was extracted from each article included the study design, country of conduct,
the demographics of the studied population (number of children, gender distribution, mean age at
study entry), how picky eating was diagnosed/defined, the prevalence of picky eating, and the method
of dietary intake assessment (if relevant). Food/food group preferences and nutritional intakes (i.e.,
of energy, macronutrients, vitamins, and minerals) were compared between picky and non-picky eaters.
Additionally, the growth/body weight status of picky and non-picky eaters was compared.
3. Results
3.1. Overview of the Identified Studies

A total of 38 publications were identified in which the effects of picky eating on food preferences,
nutritional intakes, or growth/body weight were assessed. An overview of the publications is provided
in Table 1. As can be seen in Table 1, the studies have been grouped according to the type of tool that
was used in the classification of children as picky versus non-picky eaters; the research is dependent
on the classification system employed. The tools were categorized into one of three categories; namely:
(i) Use of a single closed-ended question with a Yes/No response to the question, “Is your child a picky
eater?”; (ii) Use of a single question with a response selected from several possible pre-established
responses; or (iii) Use of several questions and a combination of responses.
A single closed-ended question was used to determine whether the child was or was not a picky
eater in three studies [3,9,12]. In these three studies, the mean age of the children ranged from 6 to 36
months, and the prevalence of picky eating ranged from 12.3 to 49%.
In 14 studies, a single question with pre-defined responses was used to establish whether the
child was a picky eater [1,5–8,13–21]. Although a similar question (i.e., “Is your child a picky eater”)
was used in several of these studies to identify children who were picky eaters, the frequency at which
the question was asked, and the cut-offs used to identify picky eaters, differed across the studies,
even across studies conducted by the same research group. For example, in an earlier study by Jacobi
et al. [5], the question “Is your child a picky eater?” was used to identify children who were picky
eaters; the question was asked at two different interviews, and to be classified as a picky eater, a score
of at least 3 (“sometimes”) at one of the two interviews and a score of at least 4 (“often”) at the other
interview were required. In contrast, in a later study by Jacobi et al. [1], there was only a single
interview, and for a child to be classified as a picky eater, the caregiver had to respond with a score of
at least 3 (“sometimes”) to the question “Is your child a picky eater?”. In the study by Boquin et al. [8],
the question “Is your child a picky eater” was asked a total of five times during the research, and to
be considered a picky eater, the average score had to be 3 or greater, where scores of 3, 4, or 5 were
defined as “sometimes”, “often”, or “always”, respectively. Across the 14 studies, the average age of
the children ranged from 4 months to 12.7 years, and the prevalence of picky eating ranged from 6.6
to 59.3%. Of note, when the criteria that defined picky eating were more stringent (e.g., “very picky
eater”, “very choosy”, “choosy most of the time”, or “definitely faddy”), the prevalence of picky eating
was much lower (e.g., approximately 15% or less).
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Table 1. Key Characteristics of the Identified Studies a .

Study Design, Assessment of Method of Dietary Intakes Growth and/or Dietary Intakes Assessed
Reference Sample Size, Age Classification of Picky Eating Prevalence of Picky Eating b
Country Growth Assessment Concurrently with Picky Eating
Use of a Single Closed-ended (Yes/No) Question (n = 3 studies)
Cross-sectional n = 1414 Caregiver responded “yes” when asked if their
Li et al., 2017 [12] 12.3% to 36.1% Yes One 24-h recall. Yes
PRC 6 to 35 mo child was a PE.
Carruth and Longitudinal n = 71 Caregiver responded “yes” when asked if their 2-day food record and one
30% to 49% Yes Yes
Skinner, 2000 [3] U.S. 34 to 84 mo child was a PE. 24-h dietary recall.
Carruth et al., 1998 Cross-sectional n = 118 Caregiver responded “yes” when asked if their 2-day food record and one
36% Yes Yes
[9] U.S. 24 to 36 mo child was a PE. 24-h dietary recall.
Use of a Single Question with a Response Selected from Several Possible Responses [n = 14 studies]
Parent responded “picky” or “a little picky” to: No. Growth and food intakes were
Rohde et al., 2017 Cross-sectional n = 271 Picky: 16%
“How would you describe your child’s way of Yes 4-day dietary records. assessed 15 mo after the assessment of
[13] Denmark 2 to 6 y A little picky: 42%
eating?” picky eating.
Caregiver responded “no”, “yes, quite choosy”, No. picky eating was assessed when
Taylor et al., 2016 Longitudinal n = 7420 or “yes, very choosy” to: “Does your child have 9.7% to 14.7% children were aged 2, 3, 4.5, and 5.5 y of
No 3-day food record.
[14] UK 2 to 7.5 y definite likes and dislikes as far as food is age. Dietary intakes were assessed at 3.5
concerned?” and 7.5 y of age.
Caregivers responded either “a very picky
van der Horst et Cross-sectional n = 2371 Somewhat PE: 27.9% to 40.4%
eater”, or “a somewhat picky eater” to: “Is No One 24-h food recall. Yes
al., 2017 [15] U.S. 1 to 4 y Very PE: 6.6% to 15.2%
your child a PE?”
Xue et al., 2015 Cross-sectional n = 793 Caregiver responded “sometimes” or “always” 24-h dietary record/recall on
59.3% Yes Yes
[16] PRC 7 to 12 y to: “Is your child a PE?” weekdays.
Xue et al., 2015 Cross-sectional n = 937 Caregiver responded “sometimes” or “always” 24-h dietary record on
54% Yes Yes
[17] PRC 3 to 7 y to: “Is your child a PE?” weekdays and FFQ.
Cross-sectional Child was considered a PE if the average score Over a 2-week in-home meal
Boquin et al., 2014 study and in-home n = 170 was ≥3 to the question: “Is your child a picky study, parents rated their own
48.8% No Yes
[8] meal test study 2 to 4 y eater?”; possible responses were 1=never, and their child’s liking of
U.S. 2=rarely; 3=sometimes; 4=often; 5=always. standardized meals.
Caregiver responded “yes, quite choosy” or
Northstone and Cross-sectional n = 9599 Yes, quite choosy: 31.2%
“yes, very choosy” to the statement: “Child has No FFQ. Yes
Emmett, 2013 [18] UK 2y Yes, very choosy: 9.8%
definite likes/dislikes”.
Caregiver responded “yes most of the time” or Choosy most of the time: No. picky eating behavior was assessed at
Jones et al., 2010 Cross-sectional n = 7285 Three 24-h unweighted food
“sometimes” to the statement: “He/she is 15.8% No 65 mo of age. Dietary intakes were
[19] UK 7y records.
choosy about food”. Choosy sometimes: 40.8% assessed at 7 y of age.
Mascola et al., Cross-sectional n = 120 Caregivers responded either “often” or
22% Yes Not assessed. Yes
2010 [7] U.S. 11 y “always” to: “Is your child a PE?”
Jacobi et al., 2008 Cross-sectional n = 426 Caregivers responded with at least “sometimes”
[1] Germany 7.7 to 12.7 y to: “Is your child a PE?”
Caregiver responded “definitely” to the Definitely faddy: 8% Yes. The change in weight starting from
Wright et al., 2007 Cross-sectional n = 455
question regarding their child’s faddy eating Maybe faddy: 15% Yes Not assessed. birth was used to calculate the Thrive
[6] UK 30 mo
behavior. Eating problem: 20% Index.
Carruth et al., 2004 Cross-sectional n = 2854 Caregivers responded that their child was a
19% to 50% Yes One 24-h dietary recall. Yes
[20] U.S. 4 to 24 mo “very PE” or a “somewhat PE”.
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Table 1. Cont.
Caregivers responded with at least “sometimes”
One laboratory and two 24-h
Jacobi et al., 2003 Cross-sectional n = 135 (score of 3) to: “Is your child a PE?” at one of the
21% Yes in-home standardized food Yes
[5] U.S. 3.5 and 5.5 y two interviews and at least “often” (score of 4)
intake tests.
at the other interview.
Chatoor et al., 2000 Case-control n = 68 Caregiver described their child as being “often”
Not applicable Yes Not assessed. Yes
[21] U.S. 12 to 37 mo or “always” a PE.
Use of Several Questions and a Combination of Responses [n = 21]
Overall prevalence: 70.1%
Caregivers responded using a five-point scale of
Kwon et al., 2017 Cross-sectional n = 184 Eating small amount: 29.9% Non-consecutive 3-day diet
1 (almost never) to 5 (almost always) to four Yes Yes
[22] Korea 1 to 5 y Refusal to eat specific food records.
specific questions relating to picky eating.
groups: 44.0%
Three items from the Pickiness Subscale of the
CFQ were each scored out of five. A mean score Somewhat. Picky eating was assessed at 5,
Berger et al., 2016 Longitudinal n = 181 for PE was calculated at each occasion. Persistent PE Three 24-h dietary recalls at 7, and 9 y of age. Dietary intakes and
Yes
[23] U.S. 5 to 15 y Persistent picky eating from ages 5 to 9 y was from ages 5 to 15 y: 18% each occasion. growth were assessed at 5, 7, 9, 11, 13, and
defined as having a mean PE score >3 at ≥2 of 3 15 y of age.
timepoints.
Mothers responded on a 5-point Likert scale
ranging from “strongly agree” to “strongly
No. Picky eating behaviors and food
disagree” with the following statements: “My
Antoniou et al., Longitudinal n = 1024 parenting practices were assessed at 5 y of
child’s diet consists of only few foods”, “My 5 y: 39.3% Yes FFQ (at 5 y of age).
2016 [24] The Netherlands 5 to 9 y age. Growth was assessed at 5, 7, 8, and 9 y
child is unwilling to eat many of the foods I
of age.
serve”, and “My child is picky or fussy about
what s/he eats”.
Caregiver response of “sometimes” and/or
No. Eating behaviors were assessed at 1.5
Cardona Cano et Longitudinal n = 3618 to 4018 “often” on two items of the CBCL that were FFQ of foods consumed over
13.2% to 27.6% No years of age, while dietary intakes were
al., 2015 [25] The Netherlands 1.5 to 6 y used to assess picky eating: “does not eat well” the past 4 weeks.
assessed at 14 mo of age.
and “refuses to eat”.
No. Eating behaviors were assessed at 4 y
de Barse et al., Longitudinal n = 4,191 Latent profile analysis of responses to the CEBQ
4 y: 5.7% Yes Not assessed. of age. Height, weight, and body
2015 [26] The Netherlands 4 to 6 y to come up with a “fussy eater” profile.
composition were assessed at 6 y of age.
Longitudinal
analysis of 3
cohorts: G 2I (n = 4227),
% Difficulties in Eating: 21 to Yes, but not in
Oliveira et al., 2015 G2I (Portugal), ALSPAC (n = 7620) Caregiver’s perception (based on yes/no
66% relation to PE FFQ at age 4 to 5 y. Yes, only at 4 to 5 y of age.
[27] ALSPAC (UK), EDEN (n = 892) questions) of feeding difficulties
% Food refusal: 50 to 66% status
and EDEN 0.3 to 5 y
(France)
Experimental Child’s fussiness was assessed by parental Intakes of yoghurts after

Werthmann et al., n = 32
study responses to the food fussiness sub-scale of the Not reported Yes manipulating taste, texture, Yes
2015 [28] 2.5 to 4 y
The Netherlands CEBQ. and color were assessed.
Fussy eating was assessed using the average of
Haszard et al., Cross-sectional n = 203 Assessed using three scales
four questions from the Lifestyle and Behaviour 36.5% No Yes
2010 [29] New Zealand 4 to 8 y from the CDQ.
Checklist.
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Table 1. Cont.
No. Eating behaviors, weight, and height
Tharner et al., 2014 Cross-sectional n = 4915 Latent profile analysis of responses to the CEBQ FFQ of foods consumed over
5.6% Yes were assessed at 4 y of age, while dietary
[30] The Netherlands 4y to come up with a “fussy eater” profile. the past 4 weeks.
intakes were assessed at 14 mo of age.
Latent class analysis to identify three distinct
Equit et al., 2013 Cross-sectional n = 1090 groups of children with different patterns of 34.1% were identified as Class 3:
Yes Not assessed. Yes
[31] Germany 4 to 7 y eating behaviors (Class 1: “normal eaters”; Class “selective eaters”
2: “weight worriers”; Class 3: “selective eaters”).
Longitudinal and Child’s fussiness was assessed by parental Assessed using a No. The CEBQ was completed in 2009, and
Rodenburg et al., n = 1275
cross-sectional responses to the food fussiness sub-scale of the Not reported Yes questionnaire that was based weight and food intakes were assessed in
2012 [32] 7 to 10 y
The Netherlands CEBQ. on a validated FFQ. 2009 and again in 2010.
van der Horst, Cross-sectional n = 305 Caregivers responded with a pattern of high
2012 [33] Switzerland 6 to 12 y scores on the CEBQ.
Unwillingness to eat familiar foods or try new
Ekstein et al., 2010 Case-control n = 170 foods, severe enough to interfere with daily
Not applicable Yes Not assessed. Yes
[34] Jerusalem 14 to 91 mo routines to an extent that was problematic to the
parent, child, or parent-child relationship.
Yes, but not in
Horodynski et al., Cross-sectional n = 399 The five-item PE sub-scale of the TPMBQ was A FFQ, adapted from the
Not reported relation to PE Yes
2010 [35] U.S. 25 mo (mean) used. Block FFQ, was used.
status
“Pickiness” was assessed using answers to six
Experimental Yes, but not in Intakes of pureed versus
Blossfeld et al., n = 70 questions scored on a 7-point Likert scale.
study Not reported relation to PE chopped carrots were Yes
2007 [36] 48 to 57 weeks “Fussiness” was assessed using the Fussiness
Ireland status assessed.
sub-scale of the CEBQ.
Caregiver responded that he/she: “always ate a No. Eating behaviors were assessed when
Dubois et al., 2007 Longitudinal n = 1498 different meal from that eaten by the family”; Defined as PE at all 3 the child was 2.5, 3.5, and 4.5 y old.
Yes One 24-h food recall.
[37,38] Canada 2.5 to 4.5 y “often refused to eat the right food”; and “often timepoints: 5.5% Dietary intakes, weight, and height were
refused to eat”. assessed only at age 4.5 y.
Three items from the Pickiness Subscale of the
Galloway et al., CFQ were each scored out of five. Picky eating
Cross-sectional n = 173 to 189 47% (7y) Yes (at 9 y Three 24-h dietary recalls over
2005 and 2007 was categorized using the median split of the Yes
U.S. 7 y, 9 y 48% (9 y) only) a 2-week period.
[39,40] total score, which was derived as the mean score
of the three items.
Lewinsohn et al., Cross-sectional n = 93 Exploratory factor analysis on caregiver
Not reported Yes Not assessed. Yes
2005 [41] U.S. 36 mo responses to the ORI-CEBI.
No. It appears that weight and height were
Caregiver or teacher indicated at least two of the
assessed at different time points from the
behaviors (eats small portions, refuses foods,
Rydell et al., 1995 Cross-sectional n = 240 child’s eating behaviors. The difference in
disinterested in food/does not appear hungry), 6 to 16% Yes Not assessed.
[42] Sweden 6.1 to 11.0 y time points is not clearly stated, but the
with behaviors occurring at least three to four
wording in the publication suggests this
times per week.
may be 1 to 2 y.
Abbreviations: ALSPAC = Avon Longitudinal Study of Parents and Children; CBCL = Child Behavior Checklist; CDQ = Children’s Dietary Questionnaire; CEBQ = Children’s Eating
Behaviour Questionnaire; CFQ = Child Feeding Questionnaire; EDEN = Study on the pre- and early postnatal determinants of child health and development; FFQ = food frequency
questionnaire; G21 = Generation XXI; h = hour; mo = months; n = number; ORI-CEBI = Oregon Research Institute Child Eating Behavior Inventory; PE = picky eater(s); PRC = People’s
Republic of China; TPMBQ = Toddler–Parent Mealtime Behavior Questionnaire; UK = United Kingdom; U.S. = United States; y = years. a Values in italics were calculated using information
provided in the publication. b If the prevalence of picky eating was reported for individual age groups in the publication, they are summarized as a range in this table.
Nutrients 2018, 10, 1992 7 of 30
In the remaining 21 studies, responses to a series of questions were used to determine whether
the child was a picky eater [22–42]. The tool used most frequently was the Child Eating Behaviour
Questionnaire (CEBQ) [43,44], which is a validated 35-item questionnaire, with questions scored on
a 5-point Likert scale [responses varied from “never” (score of 1) to “always” (score of 5)]. Six different
eating profiles were identified (i.e., “fussy eater”, “moderate eater”, “avoidant eater”, “responsive
eater”, “joyful eater”, “approaching eater”), and participants were assigned to one of these profiles
based on the highest probability of profile membership. Children classified as having a “fussy eater”
profile were characterized by a pattern of high scores in the food avoidance scales (i.e., food fussiness,
satiety responsiveness, and slowness in eating) and low scores on the food approach scales (i.e.,
enjoyment of food and food responsiveness). Within studies, it was demonstrated that how picky
eating was defined very much determined the prevalence of picky eating. For instance, in the study by
Kwon et al. [22], the prevalence of picky eating was 29.9% when defined by eating a small amount
of food and 44.0% when defined by a refusal to eat specific food groups. Likewise, Rydell et al. [42]
reported differences in the prevalence of picky eating, depending on where the determination was
made: 16% of the children were defined as picky eaters in school but not at home, 6% of the children
were defined as picky eaters at home but not in school, while 8.5% of the children exhibited at least one
picky eating behavior both at home and in school. Across the 21 studies, the average age of the children
ranged from 4 months to 15 years, and the prevalence of picky eating ranged from 5.5 to 70.1%.
As can be seen in Table 1, dietary intakes were assessed in 28 of the studies; across 24 of
these studies, the tools used to assess dietary intakes varied and generally included food frequency
questionnaires (FFQs) or food records (varying in duration from 1 to 4 days). In the remaining four
studies, dietary intakes were assessed experimentally; children were administered standardized test
meals, and their acceptability and intakes were assessed by parents [5,8], or the intakes of yoghurts
with differing tastes, textures, and colors [28], or pureed versus chopped carrots [36] were assessed.
Growth or body weight in picky versus non-picky eaters was assessed in 27 of the studies.
3.2. Food/Food Group Intakes in Picky and Non-Picky Eaters

Several researchers have examined whether food intakes, particularly intakes of foods from the
major food groups (i.e., cereals/grains, vegetables, fruits, dairy, and meats), differ in children perceived
to be picky eaters compared to non-picky eaters, using data collected from dietary intake surveys (i.e.,
parentally-completed 24-h dietary recalls, food records, or FFQs). These studies are summarized in
Table 2 (where the intakes of foods from the different food groups in picky and non-picky eaters are
presented), Table 3 (where the intakes of discretionary foods and mixed dishes in picky and non-picky
eaters are presented), and Table 4 (where the relationships between picky eater status and the intakes of
foods from the different food groups are presented). In addition to the studies summarized in Table 2,
Table 3, and Table 4, Boquin et al. [8] noted that non-picky eaters consumed a higher percentage of
a standardized meal when compared to picky eaters, while Northstone and Emmett [18] reported that
children who were described as “choosy” had lower dietary pattern scores, indicative of their lower
variety of foods consumed. Of note, in some of the studies reviewed, the time point at which picky
eating behavior was assessed differed from when the food intake data were collected [13,14,19,25,30].
In a few studies, food intakes and picky eating behaviors were both assessed concurrently, as well as
at older ages [23,32,37,38].
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Table 2. Food Preferences Assessed as Intakes of Foods from Major Food Groups in PE and NPE a .
Meats and Meat
Measure, Fruits Vegetables Grains and Grain Products Dairy
Reference Alternatives
Age at Intake Analysis
PE NPE PE NPE PE NPE PE NPE PE NPE
Meat
Intake as g/d, reported as mean ± SD 67.5 ± 80.2 * 49.1 ± 88.8
Li et al. [12] 45.3 ± 78.9 * 78.9 ± 121.8 66.2 ± 87.6 52.8 ± 72.8 117.3 ± 82.2 154.1 ± 139.3 298.1 ± 214.9 223.6 ± 208.9
6 to 35 mo
Eggs
26.1 ± 43.8 36.9 ± 44.4
Intake (g/d), reported as mean ± SEM
van der Horst et al. [15] 254 ± 12 263 ± 9 57.9 ± 3.8 * 69.7 ± 4.1 101 ± 4 100 ± 4 470 ± 15 458 ± 13 60.9 ± 3.2 * 76.9 ± 3.9
1 to 4 y
Total meat b
50 (43, 57) * 61 (57, 65)
46 72 25 52 – 390 (342, 437)
325 (305, 344)
(36, 56) b, * (65, 78) (19, 31) b, * (48, 57) b* Processed meat b
Intake (g/d), 24 (20, 28) 23 (20, 25)
Taylor et al. [14] reported as mean (95% CI)
Fish b
3.5 y
9 (7, 12) * 16 (14, 18)
Total meat c
52 (48, 56) * 61 (57, 65)
68 72 42 52 347 (322, 372)
– 325 (305, 344)
(62, 75) c (65, 78) (38, 46) c (48, 57) c Processed meat c
23 (21, 26) 23 (20, 25)
Fish c
15 (13, 17) 16 (14, 18)
Intake in PPE and NPE, reported as
Berger et al. [23] mean ± SEM of cup equiv d 0.70 ± 0.10 0.72 ± 0.05 0.57 ± 0.06 * 0.73 ± 0.03 – – –
5 to 15 y
Refined Dairy Fish
% of children not eating ≥10 g of food 58.8 58.9 32.5 29.3 89.1 * 86.0
Cardona Cano et al. [25] from the specific food group 4.9 3.8 46.7 * 36.0 Whole Formula Meat
14 mo
15.8 * 10.6
Rice, pasta 29.2 31.4 64.8 * 58.7
22.8 * 16.6
Refined Dairy Fish
0.05 −0.50 −0.13 0.01 −0.16* 0.0
Intake, z-score
Tharner et al. [30] 0.03 0.04 −0.21 * −0.01 Whole Formula Meat
14 mo
−0.20 * 0.08
Pasta, rice, potatoes 0.07 −0.01 −0.18 * 0.04
−0.16 −0.02
Dietary intake scores mean ± SD Rec. score ≥ 1
Haszard et al. [29] – – –
4 to 8 y (mean 6.4 y)
12.3 ± 3.9 * 14.5 ± 4
Nutrients 2018, 10, 1992 9 of 30
Table 2. Cont.
Meats and Meat
Measure, Fruits Vegetables Grains and Grain Products Dairy
Reference Alternatives
Age at Intake Analysis
PE NPE PE NPE PE NPE PE NPE PE NPE
% of children eating food from category
64 57 50 47 79 77 100 100 7 5
4 to 6 mo
Carruth et al. [20] e 7 to 8 mo 83 90 67 68 88 92 100 100 20 13
9 to 11 mo 89 89 65 76 96 96 100 100 33 45
12 to 14 mo 84 94 72 79 98 98 100 99 72 75
15 to 24 mo 87 84 77 84 95 98 97 97 86 89
# of servings per d, reported as
Galloway et al. [39] mean ± SD 1.0 ± 0.94 * 1.5 ± 1.1 1.3 ± 0.72 1.7 ± 0.89 5.9 ± 1.6 6.3 ± 1.8 2.9 ± 1.3 2.8 ± 1.2 1.4 ± 0.59 1.5 ± 0.63
9y
Abbreviations: CI = confidence interval; d = day; mo = months; NPE = non-picky eaters; PE = picky eaters; PPE = persistent picky eaters; Rec. = recommended; SD = standard deviation;
SEM = standard error of the mean; y = years. a Values appearing in bold-type font and with an asterisk (*) are significantly different between PE and NPE. b Results for those with score 2
(PE). c Results for those with score 1 (somewhat PE). d Recommend intakes of cup equiv: fruit = 3/d and vegetables = 2/d. e Significance between PE and NPE within each age group was
not reported.
Nutrients 2018, 10, 1992 10 of 30
Table 3. Food Preferences Assessed as Intakes of Discretionary Foods and Mixed Dishes in PE and NPE a .
Measure, Desserts Sugar-sweetened Beverages Savoury Snacks Mixed Dishes

Reference Age at Intake Analysis
PE NPE PE NPE PE NPE PE NPE
Intake as g/d, reported as mean ± SD
Li et al. [12] 409 ± 362 439 ± 351 – – – – – –
6 to 35 mo
Intake (g/d), reported as mean ± SEM
van der Horst et al. [15] 161 ± 10 b 140 ± 8 b – – 140.5 ± 7.8 161.4 ± 10.1 95 ± 6 110 ± 6
1 to 4 y
% of children not eating ≥10 g of food from Confections
Cardona Cano et al. [25] – 87.1 87.0 24.1 21.9
the specific food group
6.2* 4.1
14 mo
Confections
Intake, z-score RTE
Tharner et al. [30] −0.05 −0.01 0.16 * 0.06
14 mo −0.04
0.15 *
0.22 0.01
Dietary intake scores mean ± SD Rec. score ≤ 1 Rec. score ≤ 2
Haszard et al. [29] – –
4 to 8 y (mean 6.4 y)
0.9 ± 1.1 1.0 ± 1.4 2.6 ± 0.9 2.4 ± 1.0
% of children eating food from category –
14 b 12 b 41 41 14 13
4 to 6 mo
Carruth et al. [20] c 7 to 8 mo 48 b 45 b – 64 59 52 46
9 to 11 mo 58 b 61 b – 69 75 58 66
12 to 14 mo 77 b 76 b – 86 87 68 72
15 to 24 mo 86 b 89 b – 93 93 67 71
# of servings per d, reported as mean ± SD
Galloway et al. [39] 4.9 ± 2.1 * 5.8 ± 2.8 – – –
9y
Abbreviations: d = day; mo = months; NPE = non-picky eaters; PE = picky eaters; Rec. = recommended; RTE = ready to eat; SD = standard deviation; SEM = standard error of the mean;
y = years. a Values appearing in bold-type font and with an asterisk (*) are significantly different between PE and NPE. b Includes sweets, sweetened beverages and dessert. c Significance
between PE and NPE within each age group was not reported.
Nutrients 2018, 10, 1992 11 of 30
Table 4. Food Preferences Assessed as a Function of PE Status a .
Food/Food Group
Reference Relationship Measure Age at Analysis Results
Assessed
Fruits 2.9 (−18.1 to 24.0)
Vegetables 0.24 (−24.55 to 25.02)
Rohde et al. [13] β (95% CI) (relative to NPE) b 2 to 6 y (median 3.9 y)
Grains and Grain
−10.16 (−23.25 to 2.93)
Products
G21, 0.74 (0.5, 1.03)
4 to 6 mo
ALSPAC, 0.82 (0.72, 0.93) *
G21, 0.69 (0.48, 0.99) *
12 to 15 mo
ALSPAC, 0.77 (0.67, 0.88) *
Feeding difficulties ALSPAC, 0.76 (0.67,0.86) *
24 mo
EDEN, 0.67 (0.49,0.93) *
G21, 0.66 (0.58, 0.76) *
48 to 60 mo ALSPAC, 0.75 (0.67,0.84) *
EDEN, 0.72 (0.51,1.02)
G21, 1.13 (0.82, 1.56)
4 to 6 mo ALSPAC, 1.07 (0.94,1.22)
EDEN, 1.40 (0.67,2.93)
OR (95% CI) for relation-ship between early eating G21, 0.63 (0.44, 0.92) *
Oliveira et al. [27] c Fruits/Vegetables
behavior and later high fruit and vegetable intakes d . 12 to 15 mo ALSPAC, 1.03 (0.9,1.17)
Poor eating EDEN, 0.82 (0.44,1.48)
ALSPAC, 0.87 (0.76, 0.99) *
24 mo
EDEN, 1.12 (0.63,1.98)
G21, 0.71 (0.62, 0.81) *
48 to 60 mo
ALSPAC, 0.80 (0.71,0.91) *
G21, 0.87 (0.64, 1.19)
4 to 6 mo
ALSPAC, 1.07 (0.92,1.26)
G21, 0.72 (0.50, 1.04)
12 to 15 mo
ALSPAC, 0.89 (0.78,1.01)
FR/food neophobia ALSPAC, 0.84 (0.72, 0.98) *
24 mo
EDEN, 0.60 (0.46,0.79) *
G21, 0.58 (0.51, 0.67) *
48 to 60 mo ALSPAC, 0.85 (0.76,0.96) *
EDEN, 0.62 (0.47,0.82) *
Fruits β = −0.16 *
7 to 10 y (2009 analysis) Sugar/Sweetened
β = 0.03
Rodenburg et al. [32] Adjusted βq (relationship between food fussiness and Beverages
food intake)
Fruits β = -0.14 *
8 to 11 y (2010 analysis) Sugar/Sweetened
β = 0.04
Beverages
Nutrients 2018, 10, 1992 12 of 30
Table 4. Cont.
Food/Food Group
Reference Relationship Measure Age at Analysis Results
Assessed
Fruits OR = 0.641; 95% CI: 0.452 to 0.908 *
Horodynski et al. [35] Odds of consumption for PE vs. NPE 25 mo
Vegetables OR = 0.397; 95% CI: 0.271 to 0.582 *
Choosy sometimes: β = 1.82; 95% CI: 0.67 to 2.97
Fruits Not choosy: β = 2.77; 95% CI: 1.62 to 3.91 *
β is the adjusted difference in intake relative to the P for trend: <0.001
Jones et al. [19] reference category “choosy most of the time”, which is 7y
set at zero. Choosy sometimes: β = 1.64; 95% CI: 1.03 to 2.24 *
Vegetables Not choosy: β = 2.57; 95% CI: 1.87 to 3.27 *
P for trend: <0.001
Fruits/Vegetables (>5 PE reported once or twice: OR = 0.733; 95% CI: 0.508 to 1.058
servings) PE reported at all 3 ages: OR = 0.570; 95% CI: 0.278 to 1.169
Odds of eating specified # of servings from each food Grain products (>5 PE reported once or twice: OR = 0.781; 95% CI: 0.545 to 1.118
Dubois et al. [37,38] group relative to the group for which picky eating was 4.5 y e servings) PE reported at all 3 ages: OR = 0.635; 95% CI: 0.317 to 1.272
“never reported”, which was set at 1.0. Milk products (≥2 PE reported once or twice: OR = 0.831; 95% CI: 0.646 to 1.069
servings) PE reported at all 3 ages: OR = 0.843; 95% CI: 0.532 to 1.335
Meat and alternatives PE reported once or twice: OR = 0.628; 95% CI: 0.479 to 0.823 *
(≥2 servings) PE reported at all 3 ages: OR = 0.319; 95% CI: 0.181 to 0.560 *
rs (value for relationship between pickiness and food
Galloway et al. [40] 7y Vegetables rs = −0.21 *
intake level).
Abbreviations: ALSPAC = Avon Longitudinal Study of Parents and Children; β = regression coefficient; CI = confidence intervals; EDEN = Study on the pre- and early postnatal
determinants of child health and development; FR = food refusal; G21 = Generation XXI; mo = months; NPE = non-picky eater(s); OR = odds ratio; PE = picky eater(s); rs = Spearman
correlation coefficient; y = years. a Values appearing in bold-type font and with an asterisk (*) are significantly different between PE and NPE. b Values reported (β coefficients and
95% CI) are the results of linear regression models [adjusted for baseline measures of outcome, group (intervention/control), age, sex, and maternal education]. c “Feeding difficulties”
corresponds to feeding difficulties (ALSPAC, GEN21, EDEN), “poor eating” corresponds to eats small quantities at each meal (at 4 to 5 mo) and does not eat enough (at 12 to 15 mo)
(ALSPAC; Generation 21) and needs to be stimulated (at 4, 12 and 24 mo)(EDEN). “Food refusal” corresponds to refusal of milk (at 4 to 6 mo) and solids (at 12 to 15 mo) (ALSPAC, G21).
“Food neophobia” was calculated as the mean of three questions [≥median (more neophobic) vs. <median (reference category)] (EDEN). d A high fruit intake was defined as >1 serving/d,
and a high vegetable intake was defined as >1 serving/d, except in G21 (>3 serving/d). Subsequent intakes were assessed at age 4 y in G21, 4.5 y in ALSPAC, and 5 y in EDEN. e Eating
behavior was assessed at 2.5, 3.5, and 4.5 years. A NPE was defined as a child for whom picky eating was not reported at any of the three ages. A PE was defined in two ways: (i) as a child
for whom picky eating was defined at one or two ages (“reported once or twice”); or (ii) a child for whom picky eating was defined at all three ages (reported at all three ages).
Nutrients 2018, 10, 1992 13 of 30
The intakes of foods from the various food groups were reported differently across the studies.
In several of the studies, intakes in picky versus non-picky eaters were reported as amounts of
foods consumed (in g/day) from specific food groups [12,14,15] or as the number of servings or cup
equivalents of foods from specific food groups [23,39]. In other studies, the results were reported as
the odds of consuming foods or a certain number of servings of foods from a specific food group in
picky versus non-picky eaters [13,27,35,37,38]. While Carruth et al. [20] reported on the percentage
of picky versus non-picky children who consumed foods from the various food groups, Cardona
Cano et al. [25] reported on the percentage of picky versus non-picky eaters who did not consume at
least 10 g/day of foods from the specific food group. In the remaining studies, differences between
picky and non-picky eaters were reported as beta coefficients [13,19,32], dietary intake scores [29,30],
or correlation coefficients [40].
Carruth et al. [20] reported that no major differences were evident in the proportion of picky
versus non-picky eaters (age 4 to 24 months of age) who consumed foods from each of the major food
groups. However, the data were not analyzed statistically, and the intakes of foods from the major
food groups were assessed based on a single 24-h dietary recall, with any amount of food that was
consumed qualifying the child as a consumer of that food group.
Fruits and vegetables: Significantly lower intakes of vegetables were reported in picky versus
non-picky eaters in 10 of 13 studies [12,14,19,23,25,30,33,35,39,40]. The intakes of fruits were
significantly lower in picky versus non-picky eaters in 7 of the 13 studies [12,14,19,29,32,35,39].
When fruit and vegetable intakes were assessed collectively as one group, intakes were significantly
reduced in picky versus non-picky eaters in the majority of analyses conducted by Oliveira et al. [27],
but not in the analysis conducted by Dubois et al. [37,38]; however, in this latter study, the odds of
consuming five or more servings of fruits and vegetables in picky versus non-picky eaters was assessed.
Grain and grain products: There was generally no difference between picky and non-picky eaters
in the intakes of grains and grain products [12,13,20,33,37–39]; however, when intakes of grains and
grain products were separated further into refined, whole grain and starchy grains (e.g., rice, pasta,
potatoes), differences between picky and non-picky eaters became more discernible. Specifically, in the
study by Cardona Cano et al. [25], intakes of refined grains and grain products were similar between
picky and non-picky eaters; but, intakes of whole grains and rice and pasta were significantly lower
in picky versus non-picky eaters. Likewise, in the study by Tharner et al. [30], intakes of refined
grains and pasta, rice and potatoes, when expressed as z-scores, were not different between picky and
non-picky eaters; however, intakes of whole grains, when expressed as z-scores, were significantly
lower in picky versus non-picky eaters.
Dairy intakes: Dairy intakes—including formula intakes—were largely similar between picky
and non-picky eaters [12,20,25,30,33,37–39], except in the study by Taylor et al. [14], wherein picky
eaters (but not somewhat picky eaters) were noted to have significantly greater intakes of dairy
compared to non-picky eaters.
Meats and meat alternatives: In the majority of studies, meat intakes were significantly lower
in picky versus non-picky eaters [14,25,30,33,37,38]. In two studies, meat intakes between picky
and non-picky eaters were not significantly different [20,39], and in one study meat intakes were
significantly greater in picky versus non-picky eaters [12]. Intakes of eggs, which were assessed
individually only in one study, were significantly lower in picky versus non-picky eaters [12].
Fish intakes were significantly lower in picky versus non-picky eaters in all three studies in which
this was assessed [14,25,30]. Intakes of processed meats in picky versus non-picky eaters, which were
assessed in a single study, were similar [14].
Intakes of specific foods or food categories: In some of the identified studies, the intakes
of generally well-liked but unhealthy foods (e.g., desserts, confectionaries, savory snacks,
and sugar-sweetened beverages) in picky versus non-picky eaters were assessed. The outcomes
of these studies are largely inconsistent. For example, children identified as picky eaters at 1.5 years
of age were more likely to refuse confectionaries at the age of 14 months compared to non-picky
Nutrients 2018, 10, 1992 14 of 30
eaters [25], yet the children who were later identified as fussy eaters at the age of 4 years consumed
significantly more quantities of savory snacks and confectionaries when they were younger (at age 14
months) compared to non-fussy eaters [30]. In studies in which eating behaviors and dietary intakes
were assessed at the same time point, picky eating was associated with significantly lower intakes of
“fats and sweets” in 9-year-old girls [39], but not in two other studies in children 1 to 4 years of age [33]
and 2 to 6 years of age [12], in which intakes of sweets and desserts were similar in picky and non-picky
eaters. No differences were reported between picky and non-picky eaters in intakes of sugar-sweetened
beverages [29,30,32] and savory snacks [33], except in one study in which a significantly higher intake
of savory snacks was reported in picky versus non-picky eaters [30]. Overall, there was a limited
number of studies in which the intakes of specific foods or categories of foods in picky and non-picky
eaters were compared.
3.3. Energy, Macronutrient and Fiber Intakes in Picky and Non-Picky Eaters
Several investigators have compared the energy, macronutrient, and fiber intakes of picky eaters
and non-picky eaters. The results of these studies are presented in Table 5. It should be noted that
in the study by Carruth and Skinner [3], intakes of energy and protein were assessed in picky eaters,
but not in non-picky eaters. Thus, intakes of energy and protein in picky eaters were compared to
age-specific dietary recommendations by the study authors.
Energy intakes were noted to be significantly lower in picky versus non-picky eaters in six
studies [5,16,17,20,22,25,37,38]; but, in nine other studies, energy intakes in picky and non-picky eaters
were similar [3,9,12–14,17,24,30,39]. The ability to discern a difference in energy intakes between picky
and non-picky eaters may be a function of how picky eating is defined. For instance, in the study by Kwon
et al. [22], energy intakes were significantly lower in picky eaters versus non-picky eaters when picky
eating was defined as “eating small amounts”, but not as “the refusal of ≥2 food groups”. In several of
the other studies in which energy intakes were found to be significantly lower in picky versus non-picky
eaters, picky eating was defined using more than one qualifying criterion. For example, in the study
by Cardona Cano et al. [25], picky eating was defined as “sometimes” or “often” does not eat well and
refuses to eat. In the study by Dubois et al. [37,38], picky eating was defined as “always” ate a different
meal from that eaten by the family, “often” refused to eat the right food, and “often” refused to eat. In the
study by Jacobi et al. [5], caregivers had to answer at least “sometimes” at one interview and “often” at
the other interview to the question, “Is your child a picky eater?”.
Intakes of the macronutrients were generally reported in grams/day or as a percentage of total
daily energy intake. Protein intake was reported to be significantly lower in picky versus non-picky
eaters in five studies [14,16,17,37,38] [only in “very choosy” but not “quite choosy” children]; [13] but
not in five other studies [9,12,20,22,39]. Carbohydrate intakes were reported to be significantly lower
in picky versus non-picky eaters in two studies [20], in infants aged 7 to 8 months; [16,17]; however,
in one study [37,38], the percentage contribution of carbohydrate to total daily energy intake was
significantly greater in picky versus non-picky eaters. In the majority of studies, picky and non-picky
eaters were found to have similar intakes of carbohydrate [9,12–14,17,20,22,39]. Intakes of fat were
generally similar in picky and non-picky eaters, with significant differences reported only in three
studies. Specifically, fat intakes were reported to be significantly lower in picky versus non-picky eaters
in two studies [20], in infants 9 to 11 months but not in infants 7 to 8 months; [37,38] and significantly
greater in picky versus non-picky eaters in a single age group in one study [12]. Fiber intakes in picky
and non-picky eaters were assessed only in four studies, and although intakes were consistently lower
in picky versus non-picky eaters in all four studies, the differences between groups were significant
only in two studies [16,39].
The effects of early eating behavior on later intakes of macronutrients were assessed in a limited
number of longitudinal studies. Dubois et al. [37,38] reported that children who were considered
to be picky eaters at age 2.5, 3.5, or 4.5 years consumed significantly less fat (by 3 g), significantly
less protein (by approximately 6 g) and significantly more carbohydrate (by about 1.2 g) at age
Nutrients 2018, 10, 1992 15 of 30
4.5 years, in comparison to children who were never reported to be picky eaters. Taylor et al. [14]
reported that children with persistent picky eating during the ages of 2.0 to 5.0 years relative to those
with no persistent picky eating behaviors had slightly but significantly lower intakes of protein (by
approximately 2 g), and slightly but significantly greater free sugar intakes (by approximately 1 g),
but similar fat and total carbohydrate intakes at 7.5 years of age.
3.4. Micronutrient Intakes in Picky and Non-Picky Eaters

With regard to the intakes of vitamins and minerals (see Tables 6–8), Carruth et al. [20] have
reported that intakes of certain vitamins and minerals, among infants 7 to 11 months old may be
significantly lower among picky eaters in comparison to non-picky eaters. Even so, the study authors
noted that the mean levels of intake for all nutrients were well above the recommended dietary
allowances (RDA) or adequate intakes (AI) for both picky and non-picky eaters [20]. In a study of
9-year-old girls, picky eaters had significantly lower intakes of vitamin E, vitamin C, and folate [39],
and the reduced intakes are likely reflective of their selective food preferences and lower intakes of
specific food groups such as fruits and vegetables. Interestingly, the proportion of girls considered to
be “at risk” for nutrient inadequacy (i.e., not meeting the Estimated Average Requirements [EAR]) was
significantly higher in picky compared to non-picky eaters for vitamin E (98% versus 88%, respectively)
and for vitamin C (28% versus 12%, respectively), but not for folate (30% versus 23%, respectively) [39].
Recent studies consistently show lower intakes of iron, zinc, and vitamins A, C, E, B1, B2, and B3 among
picky eaters compared to non-picky eaters [12,14,16,17,22], although intakes of most of these nutrients
do not appear way below the recommendations. Of note, some nutrients such as iron, zinc, and vitamin
D are low among both picky and non-picky eaters. To exemplify this, in the Avon Longitudinal study,
one-half to three-fourths of all the children (including both picky and non-picky eaters) had intakes
below the recommended levels for iron and zinc, although a significantly higher number of picky
eaters had intakes of iron below the recommended intakes when compared to non-picky eaters [14].
3.5. Growth/Body Weight Status in Picky and Non-Picky Eaters

The relationship between picky eating and growth has been examined in numerous studies,
as summarized in Table 9. It has been reported in some studies that compared to non-picky eaters,
picky eaters have statistically significantly lower body mass indices (BMIs) [16,17,22,24,26,30,32,39],
lower percentages of body fat [39], and lower fat mass and fat-free mass indices [26]. In some of these
studies, when compared to non-picky eaters, picky eaters were also more likely to be classified as being
underweight [30], and were less likely to be overweight or obese [24,39]. Picky eaters were reported to
have a greater odds of being underweight [34,37]; moreover, having a higher weight-for-age has been
associated with significantly lower odds of being a picky eater [20]. In one study, the change in the
BMI standard deviation scores between picky eaters and non-picky eaters, which was evaluated from
4 to 6 years, was significantly smaller in picky eaters, mainly driven by a decrease in fat-free mass [26].
Picky eaters have also been reported to be shorter in height compared to non-picky eaters [16,24].
As with the assessment of food intakes, in some of the studies reviewed, the time point at which
picky eating behavior was evaluated was not necessarily the same as when growth parameters were
measured [13,23,24,26,32,37,38,42].
In contrast, other investigators have not observed any significant associations between
anthropometric measures and picky eating behaviors. It was reported in a number of studies that
there is no statistically significant difference in mean body weight or height [3,9,34], BMI [1,5,7,28,41],
BMI z-scores [13], proportion of children underweight [12,23], overweight [12] or in changes in BMI
over a longitudinal follow up of 15 months [13] between picky and non-picky eaters. Rydell et al. [42]
reported that “choosy children” were not significantly more likely to have weight:height scores of
-1 standard deviation, and van der Horst [33] found that picky eaters were not more likely to be
underweight compared to children with less picky eating behaviors. Similarly, Equit et al. [31] reported
that “selective eaters” were not significantly more likely to be underweight.
Nutrients 2018, 10, 1992 16 of 30
Table 5. Intakes of Energy and Macronutrients in PE and NPE a .
Age Range at Energy Carbohydrate Protein Fat Fiber

Reference Intake Analysis [kcal/day (kJ/day), (kJ/kg BW)] [g/d (%E)] [g/d (%E)] [g/d (%E)] (g/d)
(mean) PE NPE PE NPE PE NPE PE NPE PE NPE
Rohde et al. 2 to 6 y −121.3 0.72 −1.17 0.29
– – – – – –
[13] b (3.5 y) (−487.8; 245.1) (−1.20; 2.63) (−2.02; −0.32) * (−1.50; 2.09)
173.3 204.4 46.2 53.6 30.8 35.7
Kwon et al. 1 to 5 y 1155 d, * 1340 – –
(60%) d (61%) (16%) d (16%) (24%) d (24%)
[22] c (2.8 y)
189.2 204.4 50.4 53.6 33.6 35.7
1261 e 1304 – –
(60%) e (61%) (16%) e (16%) (24%) e (24%)
108.3 105 23.5 24.2 23.2 25.7 1.7 2.1
6 to 11 mo 727 744
(59.6%) (56.5%) (12.9%) (13.0%) (28.7%) (31.1%) (0.47%) (0.56%)
Li et al. [12]
150.1 154.8 39.3 41.3 39.9 41.0 3.5 4.3
12 to 23 mo 1108 1146
(54.2%) (54.0%) (14.2%) (14.4%) (32.4%) (32.2%) (0.63%) (0.75%)
159.8 165.5 46.2 45.0 43.9 * 39.4 5.7 5.9
24 to 35 mo 1200 1182
(53.3%) (56.0%) (15.4%) (15.2%) (32.9%) (30.0%) (0.95%) (1.0%)
175 178 46.1 47.9 55.9 55.2
Taylor et al. 1350g 1363
3.5 y (51.9%) g (52.2%) (13.7%) g (14.1%) (37.3%) g (36.5%) – –
[14] f
176 178 44.7 * 47.9 56.9 55.2
1346h 1,363
(52.3%) h (52.2%) (13.3%) h (14.1%) (38.1%) h (36.5%)
Antoniou et al.
9y (329) (324) – – – – – – – –
[24]
169 * 198 46.2 * 54.9 49.6 56.9 5.03 * 6.37
Xue et al. [16] 7 to 12 y 1297 * 1470
(52.1%) (53.9%) (14.3%) (14.9%) (34.4%) (34.8%) (0.78%) (0.87%)
214 225 51.8 * 55.8 57.8 59.3 6.8 7.6
Xue et al. [17] 3 to 7 y 1554 1628
(55.1%) (55.3%) (13.3%) (13.7%) (33.5%) (32.8%) (0.88%) (0.93%)
Cardona Cano
14 mo 1293 * 1329 – – – – – – – –
et al. [25]
Tharner et al.
14 mo 1300 1316 – – – – – – – –
[30]
Dubois et al. 212 219 52.5 * 58.6 54.5 * 57.5
4.5 y 1548 * 1625 – –
[37,38] (54.8) * (53.6%) (13.4%) * (14.2%) (31.9%) (33.3%)
Galloway et al. 248 262 62 63 63 65 11.2 * 12.7
9y 1778 1838
[40] (55.7%) (57.1%) (14.0%) (13.7%) (31.7%) (31.9%) (1.26%) (1.38%)
108 119 14.2 16.3 33 33
Carruth et al. 7 to 8 mo 785 * 838 – –
(55%) (56%) (7.3%) (7.8%) (37%) (36%)
[20]
130 138 19.0 23.8 35 * 38
9 to 11 mo 911 * 989 – –
(57%) (56%) (8.3%) (9.6%) (34%) (35%)
3.5 y i 1559 1546 – – – – – – – –
Jacobi et al. [5]
5.5 y i 1589 * 1659 – – – – – – – –
Nutrients 2018, 10, 1992 17 of 30
Table 5. Cont.
Age Range at Energy Carbohydrate Protein Fat Fiber

Reference Intake Analysis [kcal/day (kJ/day), (kJ/kg BW)] [g/d (%E)] [g/d (%E)] [g/d (%E)] (g/d)
(mean) PE NPE PE NPE PE NPE PE NPE PE NPE
49 ± 14 53 ± 15
34 mo 1468 ± 318 1300 j – – 16 j – – –
(13.3%) (32.5%)
Carruth and
46 ± 14 45 ± 13
Skinner [3] j 42 mo 1380 ± 261 1300 j – – 16 j – – –
(13.3%) (29.3%)
56 ± 18 61 ± 21
60 mo 1716 ± 426 1800 j – – 24 j – – –
(13.1%) (32.0%)
60 ± 17 62 ± 15
72 mo 1762 ± 388 1800 j – – 24 j – – –
(13.6%) (31.7%)
58 ± 18 64 ± 16
84 mo 1812 ± 338 1800 j – – 24 j – – –
(12.8%) (31.8%)
Carruth et al. 198.8 196.8 49 52 53 53
24 to 36 mo 1468 1472 – –
[9] (54.2%) (53.5%) (13.3%) (14.1%) (32.5%) (32.4%)
Abbreviations: β = regression coefficient; BW = body weight; CI = confidence intervals; d = day; mo = months; NPE = non-picky eater(s); PE = picky eater(s); y = years; %E = percentage of
total energy. a Values are means, unless otherwise indicated. Values appearing in bold-type font and with an asterisk (*) are significantly different between PE and NPE. Values in italics
were calculated using information provided in the publication, as well as the standard Atwater factors of 4, 4 and 9 kcal per gram of carbohydrate, protein and fat, respectively. For dietary
fiber, a caloric value of 2 kcal per gram was used. If dietary fiber was not reported and levels of some of the macronutrients were missing, then these were estimated assuming dietary fiber
was 0 g/d. b Values reported are coefficients from adjusted linear regression models (adjusted for baseline measures of outcome; group intervention/control, age, sex, and maternal
education) (β, 95% CI), in order to examine the influence of pickiness on nutrient energy intake (kJ) and macronutrients (% E), after 15 mo follow-up. Only results for PE and not “a little
picky” are presented in this table. c The energy and macronutrient intakes of children with four PE behaviors relative to NPE children were studied by the authors (i.e., eating small
amount, refusal to eat specific food groups, neophobic behavior, and preference for a specific food preparation method). The data presented in the table are related to the first two PE
behaviors. d The classification of PE was based on “eating small amounts”. e The classification of PE was based on the refusal of ≥2 food groups. f PE status was determined when the
children were 3 y, and dietary intakes were assessed when the children were 3.5 y. g Picky eating score 1; quite choosy (assessed with the use of a questionnaire). h Picky eating score 2;
very choosy (assessed with the use of a questionnaire). i There was a significant effect of picky eater status × gender × time in this experimental study where the food intake of children
was assessed over two separate 24-hour periods. Amongst the boys, PE and NPE increased their 24-hour caloric intake between ages 3.5 and 5.5. Amongst the girls, NPE also increased
their 24-hour caloric intake, whereas PE decreased their caloric intake, between ages 3.5 and 5.5. j Only intakes for children perceived as PE were reported by Carruth and Skinner [3].
For comparison, the dietary recommendations for the intakes of energy and protein (but not fat), as reported by Carruth and Skinner [3], are presented in this Table instead under the
column for NPE. The values reported by Carruth et al. [9] for PE (24 to 36 mo) are identical to those reported by Carruth and Skinner [3] for PE (34 mo.), however, intakes for NPE at 24 to
36 mo were reported only by Carruth et al. [9], and so the two studies are reported separately in the table.
Nutrients 2018, 10, 1992 18 of 30
Table 6. Intakes of Vitamins A, D, E and C in PE and NPE a,b .
Age at Intake Vitamin A (µg RAE/d) Vitamin D (µg/d) Vitamin E (mg/d) Vitamin C (mg/d)
Reference Analysis
PE NPE RDA/AI PE NPE RDA/AI PE NPE RDA/AI PE NPE RDA/AI
6 to 11 mo 509 ± 385 * 670 ± 564 400 – – – 7.0 ± 5.5 7.6 ± 9.2 3 45 ± 43 * 58 ± 45 50
Li et al. [12]
12 to 23 mo 908 ± 802 867 ± 801 500 – – – 11.1 ± 7.7 12.5 ± 8.7 4 88 ± 86 87 ± 93 60
24 to 35 mo 713 ± 629 691 ± 553 500 – – – 12.4 ± 8.3 12.4 ± 9.2 4 88 ± 290 69 ± 68 60
Kwon et al. [22] c,d 1 to 5 y 393 ± 205 * 460 ± 239 300 to 400 – – – – – – 77 ± 55 * 94 ± 61 15 to 25
365 370 1.7 1.8 5.7 6.2 54 55
Taylor et al. [14] d,e 3.5 y 300 to 400 15 6 to 7 15 to 25
(332, 399) (331, 409) (1.4, 2.1) (1.7, 1.9) (5.3, 6.1) (5.9, 6.4) (46, 62) (51, 59)
229 * 294 16.4 * 19.3 36 * 53
Xue et al. [16] d 7 to 12 y 400 to 600 – – – 7 to 11 25 to 45
(115, 378) (165, 430) (11.6,23.6) (12.8, 26.3) (17, 68) (28, 100)
Xue et al. [17] d 3 to 7 y 543 ± 43 482 ± 27 300 to 400 – – – 19.1 ± 0.6 19.1 ± 0.5 6 to 7 67 ± 3 64 ± 2 15 to 25
Galloway et al. [39] 9 yrs 669.7 ± 282 718.1 ± 288 600 – – – 5.6 ± 1.5 * 6.8 ± 2.3 11 67.0 ± 39 78.0 ± 39 45
7 to 8 mo – – – – – – 9.3 ± 3.0 * 11.2 ± 8.7 6 96 ± 43 * 107 ± 48 50
Carruth et al. [20]
9 to 11 mo – – – – – – 9.4 ± 4.0 9.6 ± 4.2 6 103 ± 52 105 ± 56 50
34 mo 754 ± 528 – 400 4.0 ± 2.6 – 5 4.0 ± 2.8 – 6 88 ± 74 – 15
Carruth and Skinner 42 mo 505 ± 217 – 400 3.9 ± 2.2 – 5 2.8 ± 2.0 – 6 67 ± 49 – 15
[3] f 60 mo 751 ± 372 – 500 4.3 ± 2.3 – 5 2.8 ± 2.2 – 7 68 ± 38 – 25
72 mo 766 ± 459 – 500 4.5 ± 2.3 – 5 4.2 ± 2.9 – 7 75 ± 39 – 25
84 mo 718 ± 442 – 500 4.8 ± 2.6 – 5 4.7 ± 3.9 – 7 88 ± 54 – 25
Carruth et al. [9] 24 to 36 mo 754 ± 528 780 ± 466 400 4.0 ± 2.6 4.8 ± 2.9 10 4.0 ± 2.8 4.5 ± 3.3 6 88 ± 74 93 ± 66 40
Abbreviations: AI = Adequate Intake; CI = confidence intervals; d = day; DRI = dietary reference intake; mo = months; NPE = non-picky eater(s); PE = picky eater(s); RAE = retinal activity
equivalents; RDA = recommended dietary allowance; SD = standard deviation; SEM = standard error of the mean; U.S. = United States; y = years. a Values are mean ± SD, mean ±
SEM, median (25th, 75th percentiles), or median (95% CI), as reported in the publications. b Values appearing in bold-type font and with an asterisk (*) are those for which a statistically
significant difference between PE and NPE were reported by the study authors. c Of the four PE behavior constructs studied, the results for “Eating small amounts” are presented; that is,
for children whose mean score of responses was >3 were classified as “PE”. d The RDA/AI for the nutrients were NR in the publication; therefore, the U.S. DRIs have been used for the
appropriate age range. e Dietary intakes assessed at 3.5 y are presented for children categorized as PE or NPE at 3 y; values presented are for the comparison of the “not choosy” group
versus “very choosy”. Dietary intakes of PE and NPE at 7.5 y are not reported in this table, as PE status was assessed 2 y earlier. f Intakes for children perceived as PE were reported in the
publication by Carruth and Skinner [3], while Carruth et al. [9] additionally reported values for NPE; however, the RDA for vitamin C was reported as 40 mg/d by Carruth et al. [9] and as
15 mg/d by Carruth and Skinner [3]; thus, the two studies are reported separately in the table.
Nutrients 2018, 10, 1992 19 of 30
Table 7. Intakes of B Vitamins in PE and NPE a,b .

Age at Folate (µg/d) Vitamin B6 (mg/d) Vitamin B12 (µg/d) Thiamine (mg/d) Riboflavin (mg/d) Niacin (mg/d)
Reference Intake
PE NPE RDA/AI PE NPE RDA/AI PE NPE RDA/AI PE NPE RDA/AI PE NPE RDA/AI PE NPE RDA/AI
Analysis
d d 0.6 ± 0.5
6 to 11 mo 82 ± 124 92 ± 89 80 0.2 ± 0.3 * 0.3 ± 0.4 0.3 – – – – – – 0.8 ± 0.6 0.5 4.6 ± 4.2 4.2 ± 3.3 3
Li et al. *
[12]
12 to 23 mo 141 ± 110 138 ± 108 120 d 0.6 ± 0.8 0.5 ± 0.5 0.4 d – – – 0.4 ± 0.8 0.4 ± 0.7 0.6 1.2 ± 1.2 1.2 ± 1.2 0.6 6.8 ± 4.4 7.7 ± 5.8 6
24 to 35 mo 178 ± 196 173 ± 170 120 d 0.5 ± 0.4 0.6 ± 0.8 0.4 d – – – 0.2 ± 0.4 0.3 ± 0.8 0.6 1.0 ± 0.8 1.1 ± 1.1 0.6 8.6 ± 5.3 8.9 ± 6.6 6
Kwon et
0.66 ± 0.78 ± 0.9 ± 0.3 8.0 ± 3.0
al. [22] 1 to 5 y – – – – – – – – – 0.5 to 0.6 1.0 ± 0.3 0.5 to 0.6 9.0 ± 3.0 6 to 8
c,d 0.24 * 0.26 * *
Taylor et 19.4 * 21.2

146 154 1.2 * 1.3 3.1 3.1 0.9 1.0 1.5 1.4
al. [14] 3.5 y 150 0.5 0.9 0.5 0.5 (18.6, (20.7, 6
d,e (138, 154) (150, 159) (1.1, 1.3) (1.3, 1.4) (2.9, 3.3) (3.0, 3.3) (0.9, 1.0) (0.9, 1.0) (1.4, 1.6) (1.4, 1.5)
20.2) 21.8)
Xue et al. 0.5 * 0.6 0.7 * 0.8 9.2 11.3
7 to 12 y – – – – – – – — – 0.6 to 0.9 0.6 to 0.9 8 to 12
[16] d (0.3, 0.8) (0.4, 0.9) (0.4, 0.9) (0.5, 1.1) (5.5, 13.5) (6.8, 16.4)
Xue et al. 11.0 ± 11.2 ±
3 to 7 y – – – – – – – – – 0.9 ± 0.1 0.8 ± 0.0 0.5 to 0.6 0.9 ± 0.1 0.9 ± 0.1 0.5 to 0.6 6 to 8
[17] d 0.3 0.3
Galloway
9y 303 ± 92 * 330 ± 87 300 1.5 ± 0.49 1.4 ± 0.41 1.0 – – – – – – – – – – – –
et al. [39]
0.73 ± 0.84 ± 1.1 ± 0.5
Carruth 7 to 8 mo 156 ± 88 190 ± 335 80 0.7 ± 0.4 0.7 ± 0.4 0.3 1.6 ± 1.1 1.7 ± 1.4 0.5 0.3 1.2 ± 0.6 0.4 9±4* 10 ± 5 4
0.3 * 0.4 *
et al. [20]
199 ± 103 0.88 ± 0.94 ± 1.3 ± 0.5
9 to 11 mo 228 ± 141 80 0.8 ± 0.4 * 0.9 ± 0.5 0.3 1.9 ± 1.1 * 2.2 ± 1.0 0.5 0.3 1.4 ± 0.6 0.4 11 ± 5 11 ± 5 4
* 0.4 * 0.4 *
34 mo 129 ± 63 – 150 1.1 ± 0.4 – 0.5 2.8 ± 1.4 – 0.9 – – – – – – – – –
Carruth
and 42 mo 153 ± 60 – 150 1.1 ± 0.4 – 0.5 2.9 ± 1.4 – 0.9 – – – – – – – – –
Skinner 60 mo 172 ± 52 – 200 1.3 ± 0.4 – 0.6 3.7 ± 1.4 – 1.2 – – – – – – – – –
[3] f
72 mo 200 ± 83 – 200 1.5 ± 0.6 – 0.6 4.0 ± 1.7 – 1.2 – – – – – – – – –
84 mo 202 ± 131 – 200 1.5 ± 0.6 – 0.6 3.7 ± 1.8 – 1.2 – – – – – – – – –
Carruth
24 to 36 mo 129 ± 63 158 ± 87 50 1.1 ± 0.4 1.1 ± 0.4 1.0 2.8 ± 1.4 3.0 ± 1.4 0.7 – – – – – – – – –
et al. [9]
Abbreviations: AI = Adequate Intake; CI = confidence intervals; d = day; DRI = dietary reference intake; mo = months; NPE = non-picky eater(s); PE = picky eater(s); RDA = recommended
dietary allowance; SD = standard deviation; SEM = standard error of the mean; U.S. = United States; y = years. a Values are mean±SD, mean±SEM, median (25th , 75th percentiles),
or median (95% CI), as reported in the publications. b Values appearing in bold-type font and with an asterisk (*) are those for which a statistically significant difference between PE and
NPE were reported by the study authors. c Of the four PE behavior constructs studied, the results for “Eating small amounts” are presented; that is, for children whose mean score of
responses was >3 were classified as “PE”. d The RDA/AI for the nutrients were not reported in the publication; therefore, the U.S. DRIs have been used for the appropriate age range.
e Dietary intakes assessed at 3.5 y are presented for children categorized as PE or NPE at 3 y; values presented are for the comparison of the “not choosy” group versus “very choosy”.
Dietary intakes of PE and NPE at 7.5 y are not reported in this table, as PE status was assessed 2 years earlier. f Intakes for children perceived as PE were reported in the publication by
Carruth and Skinner [3], while Carruth et al. [9] additionally reported values for NPE; however, the RDAs for folate and vitamins B6 and B12 were reported by Carruth et al. [9] as
50 µg/d, 1 mg/d, and 0.7 µg/d, respectively for children aged 24 to 36 mo, but were reported as 150 µg/d, 0.5 mg/d, and 0.9 µg/d, respectively, by Carruth and Skinner [3]; thus, the two
studies are reported separately in the table.
Nutrients 2018, 10, 1992 20 of 30
Table 8. Intakes of Minerals in PE and NPE a,b .
Age at Intake Calcium (mg/d) Iron (mg/d) Magnesium (mg/d) Zinc (mg/d)
Reference Analysis
PE NPE RDA/AI PE NPE RDA/AI PE NPE RDA/AI PE NPE RDA/AI
6 to 11 mo 503 ± 557 539 ± 408 400 8.3 ± 6.6 8.7 ± 6.0 10 115 ± 69 122 ± 81 70 5.3 ± 4.6 5.0 ± 3.1 8
Li et al. [12]
13.4 ±
12 to 23 mo 812 ± 736 801 ± 853 600 13.0 ± 9.0 12 144 ± 79 154 ± 99 100 7.5 ± 5.1 7.7 ± 5.6 9
9.5
15.3 ±
24 to 35 mo 650 ± 516 642 ± 536 600 15.0 ± 11.3 12 156 ± 77 162 ± 93 100 7.7 ± 4.2 7.6 ± 4.5 8
15.1
700 to
Kwon et al. [22] c,d 1 to 5 y 416 ± 146 449 ± 217 8±3* 10 ± 4 7 to 10 – – – – – –
1000
796 (740, 5.9 (5.5, 6.2) 6.5 (6.3, 4.9 (4.6, 5.3 (5.2,
Taylor et al. [14] e 3.5 y 754(728, 780) 350 6.9 – – – 5
853) * 6.6) 5.1) * 5.5)
289 (157, 1000 to 14.7 (11, 173 (121, 209 (151, 130 to 6.6 (4.6, 7.5 (5.5,
Xue et al. [16] d 7 to 12 y 330(193, 545) 12.6 (9, 18) * 8 to 10 5 to 8
471) * 1300 22) 234) * 284) 240 8.9) * 10.6)
700 to 17.3 ± 8.3 ± 0.2
Xue et al. [17] d 3 to 7 y 446 ± 24 443 ± 23 15.7 ± 0.4* 7 to 10 210 ± 5 230 ± 7 80 to 130 9.3 ± 0.4 3 to 5
1000 0.5 *
12.9 ±
Galloway et al. [39] 9y 911 ± 320 905 ± 288 1300 12.0 ± 3.9 8 212.3 ± 47.3 213.7 ± 52.7 240 8.7 ± 2.6 9.0 ± 2.6 8
3.8
7 to 8 mo 542 ± 241 597 ± 235 270 14 ± 9 * 17 ± 8 11 98 ± 43 105 ± 40 75 5±2 5±2 3
Carruth et al. [20]
9 to 11 mo 608 ± 252 * 693 ± 338 270 15 ± 10 16 ± 9 11 115 ± 44 * 131 ± 60 75 5±2* 6±3 3
34 mo 763 ± 343 – 500 9±4 – 10 157 ± 49 – 80 6±3 – 10
Carruth and Skinner 42 mo 714 ± 242 – 500 9±3 – 10 158 ± 47 – 80 7±3 – 10
[3] f 60 mo 911 ± 344 – 800 10 ± 3 – 10 192 ± 66 – 130 8±3 – 10
72 mo 878 ± 308 – 800 13 ± 4 – 10 202 ± 59 – 130 9±2 – 10
84 mo 888 ± 384 – 800 12 ± 5 – 10 196 ± 63 – 130 8±3 – 10
Carruth et al. [9] 24 to 36 mo 763 ± 343 853 ± 347 800 9±4 10 ± 7 10 157 ± 49 167 ± 57 80 6±3 6±3 10
Abbreviations: AI = Adequate Intake; CI = confidence intervals; d = day; DRI = dietary reference intake; mo = months; NR = not reported; NPE = non-picky eater(s); PE = picky eater(s);
RDA = recommended dietary allowance; RNI = Reference Nutrient Intake; SD = standard deviation; SEM = standard error of the mean; U.S. = United States; y = years. a Values are
mean±SD, mean ± SEM, median (25th , 75th percentiles), or median (95% CI), as reported in the publications. b Values appearing in bold-type font and with an asterisk (*) are those for
which a statistically significant difference between PE and NPE were reported by the study authors. c Of the four PE behavior constructs studied, the results for “Eating small amounts” are
presented; that is, for children whose mean score of responses was >3 were classified as “PE”. d The RDA/AI for the nutrients were NR in the publication; therefore, the U.S. DRIs have
been used for the appropriate age range. e Dietary intakes assessed at 3.5 y are presented for children categorized as PE or NPE at 3 y; values presented are for the comparison of the
“not choosy” group versus the “very choosy” group. Dietary intakes of PE and NPE at 7.5 y are not reported in this table, as PE status was assessed 2 years earlier. Significantly lower
intakes of selenium among PE (38.3 mg/d) versus NPE (43.6 mg/d) were reported. In terms of the % children with intakes below the recommended intakes for iron and zinc, one-half to
three-fourths of both groups of children had intakes below the RNI; however, a significantly larger number of PE had intakes of iron below the recommended intakes when compared to
NPE. f Intakes for children perceived as PE were reported in the publication by Carruth and Skinner [3], while Carruth et al. [9] additionally reported values for NPE; however, the RDA
for calcium was reported by Carruth et al. [9] as 800 mg/d for children aged 24 to 36 mo, but was reported as 500 mg/d by Carruth and Skinner [3]; thus, the two studies are reported
separately in the table.
Nutrients 2018, 10, 1992 21 of 30
Table 9. Body weight, height, and growth status of children classified as PE versus NPE.
Results Between Group

Reference Age at BL Sample Size (%PE) Outcome(s) Assessed
Statistical Significance
PE NPE
Studies where PE status was not significantly associated with impaired growth
Proportion of children OW [n (%)], defined as a
47 (14.2%) 169 (16.0%) NS
n = 1414 weight-for height z-score >2
Li et al. [12] 6 to 35 mo
(23.8%)
Proportion of children NW [n (%)], defined as
278 (84.2%) 873 (83.0%) NS
weight-for height z-score between −2 and 2
Proportion of children UW [n (%)], defined as
6 (1.6%) 11 (1.0%) NS
weight-for height z-score < 2
n = 271 BL BMI z-score [mean (95% CI)] 0.1 (−1.3;1.2) 0.1 (−1.2;1.1) NS
Rohde et al. [13] 2 to 6 y
(16%)
15-mo follow-up BMI z-score [mean (95% CI)] 0.04 (−0.13; 0.21) – NS
Werthmann et al. [28] 2.5 to 4 y n = 32 (NR) BMI – – NS
Equit et al. [31] 4 to 7 y n = 1090 (34%) Proportion UW, defined as BMI ≤ 3rd percentile 4.0% 2.8% NS
Proportion UW (internationally-based BMI
van der Horst [33] 6 to 12 y n = 305 (45%) 7.2% 9.9% NS
cut-offs)
Mascola et al. [7] 11 y n = 120 (22%) BMI – – NS
Jacobi et al. [1] 7.7 to 12.7 y n = 426 (19%) BMI (mean ± SD) 17.16 ± 2.62 17.67 ± 3.01 NS
Lewinsohn et al. [41] 3y n = 93 (NR) BMI – – NS
Age 4 y: 15.8 ± 1.2 Age 4 y: 16.4 ± 1.4 NS
Jacobi et al. [5] 3.5 to 5.5 y n = 135 (21%) BMI (mean ± SD)
Age 5 y: 15.9 ± 1.2 Age 5 y: 16.3 ± 1.4 NS
BW – – NS
Carruth and Skinner [3] 34 to 84 mo n = 71 (30 to 49%, based on age)
Body height – – NS
M: 13.3 ± 1.5 M: 13.5 ± 1.4 NS
BW, in kg (mean ± SD)
Carruth et al. [9] 24 to 36 mo n = 118 (36%) F: 12.5 ± 1.4 F: 12.5 ± 1.9 NS
M: 88.9 ± 3.8 M: 89.4 ± 3.8 NS
Body height, in cm (mean ± SD)
F: 88.1 ± 3.0 F: 86.4 ± 4.1 NS
n = 240 (6 to 16%, based on PE Home and school choosy: 26%
Proportion of children with weight:height score
Rydell et al. [42] 6 to 11 y status at school, home, and School-choosy: 14% Not choosy: 13% NS
of −1 SD
school + home) Home-choosy: 7%
Studies where PE status was associated with significantly impaired growth in some (but not all) of the parameters assessed
Children classified as PE based on “eating small amounts” a
Weight-for-age z-score −0.2 ± 0.9 0.2 ± 0.8 SS ↓ in PE
n = 184 (70.1%, overall; 29.9%,
eating small amount; 44.0%, Height-for-age z-score −0.5 ± 1.1 −0.2 ± 1.1 NS
Kwon et al. [22] 1 to 5 y
refusal to eat specific food BMI-for-age z-score 0.0 ± 1.3 0.4 ± 0.9 SS ↓ in PE
groups)
Children who refused ≥2 food groups were classified as PE for “refusal to eat specific food groups” b
Weight-for-age z-score 0.0 ± 0.9 0.1 ± 0.7 NS
Height-for-age z-score −0.3 ± 1.1 −0.2 ± 1.1 NS
BMI-for-age z-score 0.2 ± 0.9 0.3 ± 1.1 NS
Nutrients 2018, 10, 1992 22 of 30
Table 9. Cont.

PE NPE
Height, in cm (mean ± SD) 111.14 ± 6.15 112.58 ± 6.06 SS ↓ in PE
BMI, in kg/m2 (mean ± SD) 15.14 ± 1.37 15.36 ± 1.40 SS ↓ in PE
Antoniou et al. [24] 5y n = 1024 (39.3%) UW [n (%)] 86 (22.87%) 104 (17.75%) SS ↑ in PE
NW [n (%)] 269 (71.54%) 425 (72.53%) SS ↓ in PE
OW/OB [n (%)] 21 (5.59%) 57 (9.73%) SS ↓ in PE
Change in BMI from BL until 9 y in children at
risk of becoming UW and with low NW status at +0.05 (−0.11; +0.22) NA NS
BL [adjusted β (95% CI)]
Change in BMI from BL until 9 y in children at
risk of becoming OW & with high NW status at −0.08 (−0.25; +0.10) NA NS
BL [adjusted β (95% CI)]
SS ↓ in persistent PE (at
all time points, BMI
tracked along the 50th
BMI z-scores – –
percentile in PE and
Berger et al. [23] 5 to 15 y n = 197 (18% persistent PE)
along the 65th percentile
in NPE)
Prevalence of UW – – NS
5 y: 21%
7 y: 22%
Prevalence of OW/OB, defined as BMI ≥85th 9 y: 36%
<2% –
percentile 11 y: 34%
13 y: 28%
15 y: 24%
BW, in kg (mean ± SEM) 18.11 ± 0.13 18.96 ± 0.16 SS ↓ in PE
Weight for age (mean ± SEM) 0.08 ± 0.04 0.23 ± 0.05 SS ↓ in PE
n = 937
Xue et al. [17] 3 to 7 y
(54%) Height, in cm (mean ± SEM) 108.66 ± 0.33 110.45 ± 0.39 NS
Height for age (mean ± SEM) 0.18 ± 0.04 0.31 ± 0.05 NS
BMI, in kg/m2 (mean ± SEM) 15.28 ± 0.06 15.46 ± 0.07 SS ↓ in PE
BMI for age (mean ± SEM) −0.06 ± 0.04 0.04 ± 0.05 NS
Odds of being UW was
Proportion UW (weight-for-length below 5th SS ↑ in PE vs. NPE
20.6% 6.6%
Ekstein et al. [34] 14 to 91 mo n = 170 (NR) percentile) [adjusted OR = 3.6 (1.2 to
10.7)] c
BW, in kg (mean ± SD) 13.3 ± 4.3 14.1 ± 5.1 NS
Nutrients 2018, 10, 1992 23 of 30
Table 9. Cont.

PE NPE
Maybe faddy:
Not faddy:
0.2 ± 1.3 NS
z-score for BW (mean ± SD) 0.5 ± 1.2
Definitely faddy: 0.04 ± 1.1
n = 455 (8%, definitely faddy;
Wright et al. [6] 30 mo 15%, maybe faddy; 20%, eating Eating problem: No eating problem:
SS ↓ in PE
problem) 0.1 ± 1.3 0.5 ± 1.1
Maybe faddy:
Not faddy:
0.2 ± 1.4 NS
z-score for body height (mean ± SD) 0.3 ± 1.0
Definitely faddy: −0.2 ± 1.1
Eating problem: No eating problem:
SS ↓ in PE
−0.2 ± 1.3 0.3 ± 1.0
Maybe faddy:
0.3 ± 1.2 Not faddy:
Thrive Index (i.e., measure of weight gain starting NS
Definitely faddy: 0.5 ± 1.1
from birth)
0.1 ± 1.0
Eating problem: No eating problem: SS ↓weight gained since
0.1 ± 1.2 0.5 ± 1.1 birth in PE
SS ↓ in PE but PE status
was not a predictor of %
Chatoor et al. [21] 12 to 37 mo n = 68 (NR) % Ideal BW 102.4% 107.7%
ideal BW in multiple
regression analysis.
Studies where PE status was associated with significantly impaired growth in all of the parameters assessed
BMI-SDS [β (95% CI)] −0.37 (−0.47, −0.26) NA SS ↓ in PE
Fat Mass Index SDS [β (95% CI)] −0.22 (−0.33, −0.12) NA SS ↓ in PE
de Barse et al. [26] 4y n = 4191 (5.7%)
FFM Index SDS [β (95% CI)] −0.41 (−0.54, −0.29) NA SS ↓ in PE
Change in BMI SDS from 4 to 6 y, adjusting for BL 0.11 lower BMI-SDS at 6 y (95 SS ↓ in PE (due mainly to
NA
BMI at 4 y % CI: −0.19, −0.04) a decrease in FFM)
Risk of becoming UW [OR (95% CI)] 2.28 (1.34, 3.87) NA SS ↑ in PE
Child BMI z-score in 2009 (at time of PE
n = 1275 −0.08 (P < 0.01) NA SS ↓ with ↑ food fussiness
Rodenburg et al. [32] 7 to 10 y assessment)—adjusted β (P-value) d
(NR)
Child BMI z-score in 2010 (1 y after PE
−0.08 (P < 0.01) NA SS ↓ with ↑ food fussiness
assessment)—adjusted β (P-value) e
Height, in cm 135.0 ± 11.2 138.0 ± 11.2 SS ↓ in PE
Height-for-age z-score 0.13 ± 1.03 0.29 ± 1.16 SS ↓ in PE
Xue et al. [16] 7 to 12 y n = 793 (59.3%) BW, in kg 31.0 ± 9.6 34.8 ± 11.4 SS ↓ in PE
Weight-for-age z-score −0.07 ± 1.09 0.25 ± 1.17 SS ↓ in PE
BMI, in kg/m2 16.7 ± 3.0 17.9 ± 3.9 SS ↓ in PE
BMI-for-age z-score 0.09 ± 1.54 0.09 ± 1.54 SS ↓ in PE
Nutrients 2018, 10, 1992 24 of 30
Table 9. Cont.

PE NPE
BMI, in kg/m2 (mean ± SEM) 15.45 ± 0.09 15.84 ± 0.03 SS ↓ in PE
Tharner et al. [30] 4y n = 4915 (5.6%)
Proportion UW (internationally-based BMI
19.3% 12.3% SS ↑ in PE
cut-offs)
PE at 1 or 2 time points: 18.3% Never PE: 13.2% NS
Proportion UW (BMI < 10th percentile)
n = 1498 (14 to 16.9% at each
Dubois et al. [37] 2.5 y Odds of being UW was
age; 5.5% at all 3 time points)
SS ↑ for PE vs. NPE
PE at 3 time points: 26.8% Never PE: 13.2%
[adjusted OR = 2.42
(1.38–4.22)] f
PE at 1 or 2 time points: 6.9% Never PE: 9.9% NS
Proportion OW (BMI ≥ 95th percentile)
PE at 3 time points: 7.7% Never PE: 9.9% NS
BMI, in kg/m2 (mean ± SD) 17.9 ± 2.7 18.9 ± 3.4 SS ↓ in PE
Galloway et al. [39] 9y n = 173 (48%)
% Body Fat (mean ± SD) 25.6 ± 6.6% 27.8 ± 7.4% SS ↓ in PE
Proportion OW (BMI > 85th percentile) or OB
18% 43% SS ↓ in PE
(BMI > 95th percentile)
Odds of being a PE were
SS ↓ in children with
higher weight-for-age
percentiles:
0 to 25th : OR = 1.00
n = 2854 (19 to 50%, based on Odds of being a PE according to weight-for-age
Carruth et al. [20] 4 to 24 mo – – 25 to 50th : OR = 0.62 (0.45
age) percentiles
to 0.86)
50 to 75th : OR = 0.61 (0.45
to 0.84)
75 to 100th : OR = 0.66
(0.49 to 0.88)
Abbreviations: ↑ = greater; ↓ = lower; β = regression coefficient; BL = baseline; BMI = body mass index; BW = body weight; CI = confidence intervals; F = females; FFM = fat-free mass;
M = males; mo = months; n = number; NA = not applicable; NPE = non-picky eater(s); NR = not reported; NS = not significant; NW = normal weight; OB = obese; OR = odds ratio;
OW = overweight; PE = picky eater(s); SD = standard deviation; SDS = standard deviation score; SEM = standard error of the mean; SS = statistically significant; UW = underweight;
y = years. a “Eating small amounts” was a summated rating scale. Children whose mean score of response was >3 were classified as PE for “eating small amounts”. b “Refusal to eat
specific food groups” was evaluated based on the number of food groups refused. The cut-off number was set based on the mean number of food groups with responses more than
neutral (1.8 for refused food groups). Children who refused two or more food groups were classified as PE for “refusal to eat specific food groups”. c Although not explicitly stated in the
publication, it appears the OR may have been adjusted for gender and age. d Adjusted for age, gender, socioeconomic status, ethnicity, and parenteral BMI in 2009. e Adjusted for age,
gender, socioeconomic status, ethnicity, and parenteral BMI in 2010. f Adjusted for all the included behaviors and for child sex and birth weight, income level, parental overweight/obesity,
and mother’s smoking status during pregnancy.
Nutrients 2018, 10, 1992 25 of 30
Still, other studies have reported only weak associations between picky eating and growth;
for example, Wright et al. [6] reported that children considered to be “faddy” had a slight,
non-statistically significant lower body weight, height and Thrive Index (a measure of weight gain
starting from birth) compared to children who were not “faddy”. Interestingly, in this same study,
children who were perceived to have an “eating problem” did have a statistically significant lower
body weight and height and had gained less weight since birth. Chatoor et al. [21] reported that
picky eaters had a significantly lower percent ideal body weight compared to non-picky eaters (102.4%
versus 107.7%, respectively), but that picky eating status was not a significant predictor of the percent
ideal body weight [21].
4. Discussion
One of the defining features of picky eating is that the types of foods consumed tend to be limited
(i.e., selective eating), with the child exhibiting strong food preferences and food dislikes [1,3,4,6,9].
Parents of picky eaters are also more likely to report that their child does not consume an adequate
amount of food at each meal [4,8], or that the child does not eat the amount of food that the parents
think they should be eating [3,9].
There is some evidence from the literature to suggest that picky eaters do have less
intakes of certain foods/food groups compared to non-picky eaters, when intake was assessed
using data collected from dietary intake surveys (24-h dietary recalls, food records, or FFQ).
Notably, when compared to non-picky eaters, picky eaters have been reported to consume less
fruits and vegetables [12,14,15,19,23,25,27,29,30,32,33,35,39,40], whole grains [25,30], and meat and
fish [14,25,30,33,37,38], with the most consistent finding related to the reduced consumption of
vegetables in picky versus non-picky eaters. Caution is warranted in interpreting these findings
since the extent to which the parents were regulating the child’s food intake is not known. For example,
it is unclear whether the lower intake of certain food groups is attributable to the child’s refusal to eat
such foods, or whether the foods were simply not offered to the child by the parents, either because the
parents know that the child will not eat the food, or for other reasons such as affordability. To avoid
these potential confounders, several investigators have evaluated whether food intake differs between
picky eaters and non-picky eaters under an experimental setting. Similar to the data collected from
dietary intake surveys, the results from two such experimental studies identified in this review suggest
that the food choices of picky eaters do differ in some respects when compared to those of non-picky
eaters [5,8]. For instance, picky eaters were more likely to avoid vegetables in both of these studies.
Thus, vegetable intakes, which tend to be low in general, are even lower in picky eaters.
Varying results have also been reported in studies that included an assessment of energy,
macronutrient, and dietary fiber intakes. Although picky eaters had significantly lower intakes of
protein than non-picky eaters in some of the identified studies [13,14,16,17,37,38], overall, the intakes
of protein were sufficient, both in picky-eaters and non-picky eaters in all age groups assessed.
In fact, dietary protein intakes were generally in excess of the European Food Safety Authority (EFSA)
dietary recommendations for protein for all age groups. For example, using EFSA’s dietary protein
recommendations (specifically, the Population Reference Intakes, which are age- and gender-specific
and intended to meet the needs of 97.5% of the population) [45] and reference body weights for
European children [46], dietary protein recommendations are 11 to 13 g/day for children 1 to 3 years
of age. As per Table 5, dietary protein intakes among children 1 to 3 years of age—irrespective
of picky eating behavior—were 39.3 to 50 g/day, representing intakes that were 3.5- to 4.5-fold
greater than EFSA’s dietary protein recommendations. On the other hand, fat intakes were generally
low in children 1 to 3 years of age (24 to 32% E versus 35 to 40% E of EFSA’s reference intake
range [47] for this age group) in both picky eaters and non-picky eaters [3,9,12]; but, in most studies
of children 3 years of age and older [16,17,38,39], fat intakes were within EFSA’s reference intake
range of 20–35% E for this age group [47]. Dietary fiber intakes need to be increased in children in
general, regardless of whether they are a picky eaters or not, although there is evidence to suggest the
Nutrients 2018, 10, 1992 26 of 30
intake of dietary fiber may be even lower amongst picky eaters [16,39]. The data on consequences of
early picky eating behavior [14] and persistent picky eating [38] on later macronutrient intakes are
too limited to draw any conclusions. With regard to micronutrients, based on the studies reviewed
herein (in at least one of the subgroups examined), picky eaters had significantly lower intakes of
certain micronutrients such as iron [14,16,17,20,22], zinc [14,16,17,20], vitamins A [12,16], B6 [12,14,20],
C [12,16,20,22], E [16,20,39], thiamine [16,20,22], riboflavin [12,16,20,22], and niacin [14,20,22] compared
to non-picky eaters. While intakes in most of these studies were close to recommended values, Taylor
et al. [14] noted that the intakes of iron and zinc were below the recommendations in both groups,
making it equally important to address these gaps in the general population. Another way to assess
nutritional status is to directly measure the levels of micronutrients in blood samples; however, due to
the invasive nature of blood sampling, it is not often employed in large-scale studies of young children.
Two recent studies have measured the nutrient status of pre-school- and school-aged children and
reported significantly lower levels of iron, magnesium, and copper in the blood of school-aged picky
eaters compared to non-picky eaters [16], although no such differences were observed in preschool
children [17]. If the school-aged picky eaters were picky eaters earlier in life, then there is some
suggestion that the persistence of picky eating may have adverse consequences on nutritional status in
the long-term.
Rather than examining food/nutrient intakes individually, perhaps a better approach would be
to use dietary indices and/or dietary patterns reflecting the overall quality of the diet or adherence to
a dietary recommendation, the results of which may be easily understood by the general population.
As an example, the Youth Healthy Eating Index (HEI) [48] was constructed for use specifically in
children and adolescents. Other examples are the Finnish Children Healthy Eating Index (FCHEI) [49]
and the Chinese Children Dietary Index [50]; both scoring systems were developed to assess overall
diet quality among children in their respective countries.
There does not appear to be a clear association between picky eating and childhood growth/body
weight status across the studies identified in this current review. Similarly, in a recent systematic
review, Brown and colleagues [51] reported inconsistent findings among the studies evaluating whether
associations exist between picky eating or food neophobia and weight status; in comparison with picky
eating or food neophobia, 17 studies found no association with weight status, 2 studies found a positive
association with overweight status, 5 studies found a negative association with overweight or obesity
status, 6 studies found a positive association with underweight status, and 11 studies found a decreased
association with BMI or BMI z-score. It should be noted, however, that studies that used a larger
number of qualifying criteria in their classification of picky eating generally reported a significant
difference in the growth/weight status of picky versus non-picky eaters. Among the seven studies [16,
20,26,30,32,37,38] in which all parameters related to growth/weight were significantly poorer in picky
versus non-picky eaters, only in two studies [16,20] was the picky eating classification based on a single
question; in the remaining five studies [26,30,32,37,38], the classification of the children as picky eaters
was based on multiple defining criteria. Likewise, among the seven studies [6,17,21–24,34] in which
some but not all parameters related to growth/body weight were significantly inferior in picky versus
non-picky eaters, only in three studies [6,17,21] was the picky eating classification based on a single
question, while in the remaining four studies [22–24,34], the classification of the children as picky
eaters was based on multiple defining criteria. In the 12 studies [1,3,5,7,9,12,13,28,31,33,41,42] in which
there was no difference between picky and non-picky eaters in growth/body weight, in the majority
of studies (i.e., seven), the classification of picky eating was based only on a single question. Perhaps
a single question is not sufficient to differentiate picky from non-picky eaters, and the greater the
number of defining criteria, the more accurately true picky eating can be identified. In addition to how
picky eating was defined, there are other factors that could have contributed to the lack of a consistent
finding across the studies (e.g., whether the growth parameters were parentally reported or were
assessed directly by investigators and the actual growth parameter assessed). Moreover, the studies
reviewed herein consisted mainly of healthy children without any formal diagnosis of eating disorders.
Nutrients 2018, 10, 1992 27 of 30
The lack of consistent findings between picky eating and food/nutrient intake or growth/body
weight status across the different studies in the literature highlights the various challenges faced by
researchers in this field. For one, there is no concise definition for picky eating that has been widely
adopted in the literature. There are several different ways by which researchers have identified picky
eaters or defined picky eating in studies, ranging from the simple question, “Is your child a picky
eater?”, which is highly subjective and requires interpretation by the responder, to the use of more
complex tools that rely on a combination of responses related to picky eating behaviors. A single
question may not be sufficient to delineate between parental perception of picky eating and true picky
eating, and so a tool that incorporates several different eating behaviors that are problematic in picky
eaters, such as the CEBQ, may be more sensitive in identifying true picky eating. Understandably,
there are many difficulties in deriving a widely accepted definition of what constitutes picky eating.
As with any other human behavior, picky eating is highly complex; it is constantly evolving even
within an individual and is likely to change with age. However, many of the studies identified herein
were cross-sectional in design. Therefore, more longitudinal studies are needed to better characterize
picky eating over time, to better understand whether such behaviors are transient phenomena or
persist over time, and to identify the most relevant and sensitive age range wherein picky eating has
the greatest impact on food choices or health outcomes later in life. Finally, some consensus on the
most sensitive or pertinent dietary intake and growth measures is needed, as the results for these
outcomes were reported with heterogeneity across the studies. The tools used to assess dietary intakes
varied across the studies, with some using a single 24-h dietary recall, others using multiple 24-h
recalls, and others a FFQ. The way the results were expressed was also highly variable. For instance,
across studies, the intake of fruits and vegetables in picky and non-picky eaters was expressed as
amount (g) per day, the proportion of children consuming a minimum amount, or as an odds ratio.
Likewise, for body weight, there was little consistency in how the outcomes were reported across
studies (e.g., z-score, BMI, OR of being underweight, normal weight, or over weight, etc.).
There is a wealth of literature published on picky eating during childhood, and across a broad
range of ages, as evidenced from this review. There appears to be the general consensus that picky
eating (or “selective food choice”), to some extent, is a normal part of the child development process
and does not negatively impact growth or nutritional status. However, on an individual basis, it is
important to differentiate picky eating behaviors from the more serious eating disorders that could have
negative implications on health (e.g., growth impediment, nutritional deficiency, or other functional
impairments). Efforts should be made to ensure that all children, especially those with perceived picky
eating, consume a nutritionally balanced and varied diet in accordance with the recommendations set
forth in the current dietary guidelines. It is important to continue to promote healthy eating habits
among children in general, particularly in children with perceived picky eating, by providing repeated
exposure to a variety of foods, offering age-appropriate textures/portion sizes, using appropriate
feeding techniques, practicing responsive feeding, and role modelling of food choices.
The limitations of this narrative review should be mentioned. First, the evidence is predominantly
from cross-sectional studies, and it is well-known that dietary recall can be biased in such studies
(e.g., parents of children who perceive their children as picky eaters may indicate poorer dietary
intakes/habits than what the child actually exhibits). A limited number of longitudinal studies
were identified, and such studies are important in understanding whether picky eating is a transient
phenomenon with no long-term effects on growth or nutritional status or if picky eating is sustained,
with more detrimental effects on nutritional status and growth in the long-term. Another limitation
of this review is that the assessment presented herein is strictly qualitative—we did not pool results
across studies (for example, the intakes of fruits and vegetables in picky versus non-picky eaters),
and it is possible that a quantitative assessment (such as that afforded by a meta-analysis) may have
increased our sensitivity in identifying differences between picky and non-picky eaters; however,
the studies identified are too heterogeneous to pool (i.e., the studies differed considerably in how picky
eating was defined, how dietary intakes were assessed, and how growth was monitored). Finally,
Nutrients 2018, 10, 1992 28 of 30
given that the interest was in several different aspects of picky eating, such as diagnostic criteria, dietary
intakes, body weight/growth status, and overall nutritional adequacy in picky versus non-picky eaters,
the research was conducted and reported as a narrative review as opposed to a systematic review,
and so it is likely that not all relevant studies have been captured. Nonetheless, the sampling of studies
presented herein is robust, and the heterogeneity in critical research elements is evident. Research in
the area of picky eating would benefit from increased alignment in how clinical studies are designed,
how picky eating is identified, and the best methods for assessing and reporting nutritional intakes
and growth.
Author Contributions: All of the authors (T.M.S., K.M.V., M.H., C.V., Y.S.-D.) contributed to the conceptualization,
analysis, writing, and editing of this manuscript.
Funding: This research received no external funding.
Acknowledgments: The authors would like to thank Emily Booth for her assistance with the formatting of the
manuscript, and Judith Hill for her assistance in preparing the list of references.
Conflicts of Interest: Y.S.-D. and T.M.S. are employees of Nestlé Research, which is a subsidiary of Nestec SA.
The review was financed by Nestlé Research. K.M.V., M.H., and C.V. are employees of Intertek Health Sciences
Inc, which is a scientific and regulatory consultancy firm. Nestlé Research is a client of Intertek Health Sciences
Inc. This work represents the authors’ scientific opinion of published data.
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© 2018 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access
article distributed under the terms and conditions of the Creative Commons Attribution
(CC BY) license (http://creativecommons.org/licenses/by/4.0/).

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Nutrients 2018, 10, 1992; doi:10.3390/nu10121992 www.mdpi.com/journal/nutrients

3.1. Overview of the Identified Studies

Table 1. Key Characteristics of the Identified Studies a .

Experimental Child’s fussiness was assessed by parental Intakes of yoghurts after

3.2. Food/Food Group Intakes in Picky and Non-Picky Eaters

Measure, Desserts Sugar-sweetened Beverages Savoury Snacks Mixed Dishes

Table 4. Food Preferences Assessed as a Function of PE Status a .

3.4. Micronutrient Intakes in Picky and Non-Picky Eaters

3.5. Growth/Body Weight Status in Picky and Non-Picky Eaters

Table 5. Intakes of Energy and Macronutrients in PE and NPE a .

Age Range at Energy Carbohydrate Protein Fat Fiber

Age Range at Energy Carbohydrate Protein Fat Fiber

Table 6. Intakes of Vitamins A, D, E and C in PE and NPE a,b .

Table 7. Intakes of B Vitamins in PE and NPE a,b .

Taylor et 19.4 * 21.2

Table 8. Intakes of Minerals in PE and NPE a,b .

Results Between Group

Results Between Group

Results Between Group

Results Between Group

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