“I only want nuggets.”
“No vegetables!”
“She only drinks milk.”
If you are the parent of a toddler, these conversations may sound very familiar.
Picky eating is one of the most common concerns I hear in my clinic.
Parents often worry that their child is not eating enough, is missing important nutrients or that their eating habits may affect growth.
As a paediatrician and paediatric endocrinologist, growth is one of the first things I look at when assessing a child with feeding concerns.
While most picky eaters continue to grow normally, some children may develop nutritional deficiencies or have poor weight gain that can eventually affect growth and development.
The reassuring news is that picky eating is common, especially between one and five years of age.
In most cases, it is a normal part of childhood and improves with time.
However, there are situations where picky eating may be a sign of a more serious feeding or medical problem.
So how can parents tell the difference?
A natural process
Many parents notice that their baby used to eat almost everything, but suddenly becomes selective after their first birthday.
This is actually quite normal.
Growth slows down after infancy, so toddlers naturally need less food than before.
At the same time, they are learning independence and like having control over their choices.
Food is often one of the easiest ways for them to express this.
A child may happily eat carrots one week and refuse them completely the next.
While frustrating, this behaviour is often part of normal development.
Although picky eating cannot always be prevented, healthy feeding habits can begin during infancy.
When babies start complementary feeding at around six months of age, parents should gradually introduce a wide variety of foods.
This includes vegetables, fruits, grains, meat, fish, eggs and other age-appropriate foods.
The more variety babies are exposed to, the more familiar different foods become.
It is also important not to stay on smooth purees for too long.
As babies develop, they should be offered mashed foods, lumpy textures and soft finger foods appropriate for their age.
Some parents become discouraged when a baby rejects a new food.
However, this is completely normal – toddlers are naturally cautious about new foods.
They may need multiple exposures before accepting a new taste or texture.
The key is to keep offering foods in a positive and relaxed way without forcing or pressuring the child.
Early exposure to different foods and textures does not guarantee that a child will never become picky, but it can help build confidence around food and make mealtimes less stressful later on.
Watch for growth
Most picky eaters still eat foods from different food groups, even if their choices are limited.
For example, a child may dislike vegetables, but still eat fruits, rice, bread, eggs, chicken and dairy products.
As long as weight and growth are normal and they are getting a reasonable variety of nutrients, there is usually no major cause for concern.
One of the best indicators that a child is getting enough nutrition is growth.
A child who continues to gain weight appropriately and follow their usual growth curve for height is generally getting what their body needs, even if their diet is not perfect.
Children also tend to eat differently from day to day.
Some days they seem to survive on just a few bites, while on other days they eat surprisingly well.
It is better to look at what a child eats over a week rather than focusing on a single meal.
Picky eating deserves closer attention when a child’s diet becomes very restricted.
For example, some children eat only one type of food, such as plain rice, biscuits or milk, and refuse almost everything else.
Parents should also seek medical advice if picky eating is accompanied by:
- Poor weight gain or weight loss
- Faltering growth
- Fatigue or low energy levels
- Signs of vitamin or mineral deficiencies
- Significant distress during mealtimes
- Difficulty chewing or swallowing
- Gagging, choking or coughing while eating.
Growth can sometimes act as an early warning sign.
A child whose weight gain slows down, drops across growth centiles or whose height growth begins to falter may not be receiving enough calories or nutrients to support healthy growth.
Nutritional deficiencies can occur even in children who appear otherwise well.
Iron deficiency is one of the most common examples, and may cause tiredness, poor appetite and difficulties with concentration.
Deficiencies of vitamin D and calcium may also occur in children with very restricted diets, predisposing them to weak fragile bones.
A medical cause
Sometimes, children are labelled as picky eaters when there is actually another reason behind their feeding difficulties.
One group includes children with autism spectrum disorder or other neurodevelopmental differences.
These children may be very sensitive to the texture, smell, taste or appearance of food.
They may only accept foods of a certain colour, texture or brand.
Some children have difficulties with chewing or swallowing.
They may avoid certain foods because eating is uncomfortable or difficult.
Medical conditions can also affect eating. Severe reflux, chronic constipation, food allergies, iron deficiency and enlarged tonsils are just a few examples that can reduce appetite or make eating unpleasant.
This is why it is important to look at the whole child and not just the food they refuse.
A few months ago, I met a four-year-old boy whose parents were worried about his eating habits.
His diet consisted mainly of plain rice, crackers and milk.
He refused fruits, vegetables, meat and eggs.
Every meal became a struggle.
At first, his parents assumed he would eventually outgrow it.
However, over time, they noticed that his weight gain had slowed.
While he was still growing in height, his weight had dropped across several centiles on the growth chart.
Blood tests later showed iron deficiency anaemia.
Further assessment revealed sensory sensitivities.
He found many food textures overwhelming and became anxious when new foods were offered.
With support from a feeding team and a dietitian, his family learned strategies to introduce foods gradually without pressure.
Progress was slow, but over time, he began accepting a wider variety of foods and his nutritional status improved.
His story is a reminder that while many picky eaters are perfectly healthy, some children need additional support.
What can parents do?
The good news is that there are simple strategies that can help:
- Keep offering new foods
Children often need repeated exposure before accepting a new food.
Don’t give up after one attempt.
- Avoid pressure
Forcing, bribing or threatening young children to eat usually makes things worse as they will develop a negative association with the food.
- Eat together as a family
Children learn by watching others.
Family meals give them the opportunity to see parents and siblings enjoying different foods.
- Have regular meal and snack times
Constant grazing throughout the day can reduce appetite at mealtimes.
- Involve your child
Taking children grocery shopping, washing vegetables or helping prepare meals can increase their interest in food.
- Avoid distractions
Focus on the food and avoid distractions such as toys.
Avoid using tablets or handphones during mealtimes.
- Celebrate small wins
Touching, smelling or tasting a new food is often the first step before eventually eating it.
One common issue I see is toddlers filling up on milk.
While I always advocate having good dietary calcium – and milk is a good source of calcium, as well as being generally nutritious – too much after the age of one year can reduce appetite for other foods.
Children who drink large amounts of fresh milk without taking appropriate solids may become deficient in iron because they are eating less iron-rich food.
Another common subject is supplements.
Not all picky eaters need supplements.
Many children who are selective eaters are still growing normally and do not require vitamins or nutritional drinks.
However, supplements may be useful when the diet is limited, growth is affected or nutritional deficiencies are identified.
Common deficiencies seen in selective eaters are iron, vitamin D and calcium.
Parents should discuss supplements with their child’s doctor rather than relying on multiple over-the-counter products.
Supplements can help fill nutritional gaps, but they should not replace efforts to improve dietary variety.
The bigger picture
Picky eating is a normal stage of development for many toddlers.
In most cases, children continue to grow well and gradually become more adventurous eaters with time.
A child who is maintaining healthy weight gain, growing in height and meeting developmental milestones is usually getting enough nutrition, despite being selective with food.
However, parents should seek advice if a child eats an extremely limited diet, develops nutritional deficiencies, struggles with chewing or swallowing, or shows poor weight gain or growth.
Offering a variety of foods and textures during infancy, maintaining positive mealtime experiences and avoiding pressure can help children develop confidence around food.
The goal is not to create a child who eats everything on their plate, but to support healthy growth, good nutrition and a positive relationship with food.
And if growth starts to slow or mealtimes become a daily struggle, it may be time to seek professional medical help.
Dr Jeanne Wong Sze Lyn is a consultant paediatrician and paediatric endocrinologist. For more information, email starhealth@thestar.com.my. The information provided is for educational purposes only and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
