ORIGINAL ARTICLE: NUTRITION

The Pediatric Eating Assessment Tool: Factor Structure

and Psychometric Properties

Suzanne M. Thoyre, yBritt F. Pados, yJinhee Park, zHayley Estrem,
§
Cara McComish, and Eric A. Hodges

ABSTRACT

Objectives: The Pediatric Eating Assessment Tool (PediEAT) is a parent-

What Is Known
report instrument developed to assess symptoms of feeding problems in
children aged 6 months to 7 years. The purpose of this study was to identify  Difficulties with eating are common among infants
the factor structure of the PediEAT and test its psychometric properties,
and young children.
including internal consistency reliability, temporal stability, and construct  Determining if a feeding problem is significant can
validity.
be challenging.
Methods: Participants included 567 parents of children aged 6 months to 7  Feeding problem measures primarily focus on
years. Fifty-four percent of the sample had parent report of a diagnosed feeding
behavioral indicators.
problem or feeding concerns. Exploratory factor-analysis techniques were used
to remove redundant or non-endorsed items and identify the factor structure of
the instrument. Construct validity was examined with 466 parents completing What Is New
the Mealtime Behavior Questionnaire as a criterion standard. Known-groups
validation was used to compare PediEAT scores between children with and  The Pediatric Eating Assessment Tool examines
without diagnosed feeding problems. Temporal stability of the PediEAT was observable physiologic and behavioral symptoms
examined with 97 parents repeating the PediEAT after 2 weeks. of feeding problems.
Results: Principal components factor analysis with varimax rotation  The Pediatric Eating Assessment Tool can be
supported a 4-factor model accounting for 39.4% of the total variance. The used from an early age 6 months through age
4 subscales (Physiologic Symptoms, Problematic Mealtime Behaviors, 7 years.
Selective/Restrictive Eating, Oral Processing) demonstrated acceptable  The Pediatric Eating Assessment Tool is a valid
internal consistencies (coefficient alphas: 0.92, 0.91, 0.83, 0.83; respec- and reliable measure for research and clinical prac-
tively). Construct validity was supported in 2 ways. The PediEAT tice.
correlated with the Mealtime Behavior Questionnaire (r ¼ 0.77, P < 0.001)
and total score and subscale scores were significantly different between child-
ren with and without diagnosed feeding problem (P < 0.001). Temporal
stability was demonstrated through test-retest reliability (r ¼ 0.95, P < 0.001).
Conclusions: Strong psychometric properties support the use of the
PediEAT in research and clinical practice.
Key Words: feeding behaviors, feeding difficulties, feeding problems,
measurement, psychometric
F eeding problems during infancy and early childhood are
prevalent and rising in number due to increased survival
of infants with extreme prematurity (1) and medical complexity
(2), and a growing population of children with developmental
(JPGN 2018;66: 299–305) disabilities, such as autism spectrum disorder (3,4). Although we
are in need of robust epidemiological studies, up to 20% of
Received March 22, 2017; accepted September 8, 2017. typically developing children, 80% of children with develop-
From the School of Nursing, The University of North Carolina at Chapel mental disabilities, and 85% of children with complex medical
Hill, Chapel Hill, NC, the yConnell School of Nursing, Boston College, conditions are reported to experience feeding difficulties (5–8).
Boston, MA, the zCenter for Developmental Science, The University of Pediatric feeding problems are a clinical problem of high impact
North Carolina at Chapel Hill, Chapel Hill, NC, and the §Department because disruption in child feeding is associated with negative
of Allied Health Sciences, Speech and Hearing Sciences, The University
effects on child social, emotional, physical, and cognitive devel-
of North Carolina School of Medicine, Chapel Hill, NC.
Address correspondence and reprint requests to Suzanne M. Thoyre, PhD, opment, and significantly impacts parent well-being and family
MSN, BSN, Carrington Hall, CB #7460, The University of North life (5,9,10). As such, adequate assessment of symptoms of a
Carolina at Chapel Hill, Chapel Hill, NC 25799-7460 feeding problem is necessary to determine need for referral,
(e-mail: [email protected]). select appropriate treatments, and monitor treatment effective-
This study was supported by School of Nursing, The University of North ness.
Carolina at Chapel Hill and The Francis Hill Fox Distinguished Term The Pediatric Eating Assessment Tool (PediEAT) was
Professor funds. developed to assess symptoms of a feeding problem by parent
The authors report no conflicts of interest. report in young children aged 6 months to 7 years who have
This article has been developed as a Journal CME Activity by NASPGHAN. begun to eat solid foods. Symptoms are conceptualized as
Visit http://www.naspghan.org/content/59/en/Continuing-Medical-Edu-
cation-CME to view instructions, documentation, and the complete
observable behaviors and biologic function related to food,
necessary steps to receive CME credit for reading this article. eating, or mealtime. Content validity of the PediEAT has been
Copyright # 2017 by European Society for Pediatric Gastroenterology, established (11). This study aimed to identify the factor structure
Hepatology, and Nutrition and North American Society for Pediatric of the PediEAT and test its psychometric properties, including
Gastroenterology, Hepatology, and Nutrition internal consistency reliability, temporal stability, and construct
DOI: 10.1097/MPG.0000000000001765 validity.

JPGN  Volume 66, Number 2, February 2018 299

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Thoyre et al JPGN  Volume 66, Number 2, February 2018

METHODS Procedures
Setting and Sample Before the study, the on-line survey was developed and
The participants in this study were parents or caregivers piloted with 19 parents using various devices (smart phone, tablet,
(hereafter referred to as ‘‘parents’’) of young children with and laptop, or desktop computer). Feedback was elicited on survey
without feeding problems. To participate, parents had to be 18 years utilization to which parents responded positively; no adjustments
of age or older, caring for a 6 month to 7-year-old child being were needed. For the study, parents were invited to complete the
offered at least some solid foods, and self-report as being literate in PediEAT, the MBQ and a set of questions to describe parent and
English. The institutional review board of the University of North child demographics, child health, and feeding history. Following
Carolina at Chapel Hill approved the study. completion, parents were offered a gift card and the same parent
Quota sampling was used to ensure an equal distribution of was invited to repeat the PediEAT 2 weeks later to evaluate its
parents of children across the age categories between 6 months and temporal stability. This interval between tests is commonly selected
7 years on the American Academy of Pediatrics (AAP) periodicity for questionnaires measuring phenomenon that are expected to be
schedule (12). We also aimed to over-represent the sample with relatively stable across a short period yet sufficient in length to
parents of children with feeding problems to capture a thorough preclude the respondent from remembering prior answers (15,16).
representation of feeding problem symptoms. Parents of children Once a minimum of 20% of the targeted sample size completed the
with feeding problems, or at-risk for feeding problems, were retest (ie, n  97), invitations to repeat the PediEAT ended. This
recruited from a feeding specialty clinic in NC, researchmatch.org, consecutive sampling plan introduced randomness to the retest
and several on-line support groups for parents of children with sample and assured that the size of the test-retest sample exceeded
feeding difficulties. Concurrently, parents of children without feed- that which is recommended (16).
ing problems were recruited from parent support groups in NC and Data were analyzed using SPSS Statistics, Version 24.0 (IBM
MA, research volunteers at the University of North Carolina’s Join Corp, Armonk, NY). All cases with more than 10% of missing data
the Conquest registry, and from a general e-mail invite to University on the PediEAT or MBQ were excluded from the analysis.
staff, students, and faculty. All parents were asked to report on a
single child. RESULTS
A total of 613 parents from a wide geographic area across the
Measures United States and Europe completed the survey. After removal of
missing case data, the final sample included 567 parents. Thirty-
Pediatric Eating Assessment Tool four percent of the sample reported the target child had a diagnosed
The Pediatric Eating Assessment Tool (PediEAT) measures feeding problem; an additional 20% reported the child either had a
symptoms of feeding problems in young children. Content validity feeding problem or they were unsure if the child had a feeding
was established using DeVellis’ methods of scale development (13) problem. The target children represented all 11 age categories of the
through systematic item generation and evaluation by clinical and AAP periodicity schedule from 6 months to 7 years of age (12), with
research experts as well as by the intended respondents: parents of equal distributions from 6 months to 2 years (n ¼ 189), 2 to 4 years
children both with and without feeding problems. A full description (n ¼ 187), and 4 to 7 years (n ¼ 191). Children were 55% boys,
of these processes is available in a previous publication (11). The 12.7% used a feeding tube for supplemental feeding, and 23.4%
readability of the PediEAT was tested throughout the content were reported to be developmentally delayed. Respondent’s income
validation process with adjustments made so that the final version and education level varied, with 22.4% of the sample below US
was written at a less than fifth grade reading level. The final median household income. Educational attainment of the sample
PediEAT included a comprehensive set of 97 symptoms describing was higher than the US national average (17). Table 1 provides
the difficulties parents observe directly during mealtime (eg, frequencies of the target children by age group and sex. Table 2
refusal, volume limiting) and symptoms they observe to be concur- provides descriptive statistics of the parent respondents and target
rent with feeding difficulties (eg, arching, constipation, fatigue). children.
Items are worded in both the positive and negative necessitating
reverse scoring of some items. All items begin with the prefix My
child. . .; respondents are directed to ‘‘think about what is typical for
your child at this time’’ and to select from 6 response options for TABLE 1. Summary of number of target children by age and sex
each item (Never, Almost Never, Sometimes, Often, Almost Sex
Always, Always).
Male Female Total

Mealtime Behavior Questionnaire Age

6–9 months 9 13 22
To assess construct validity, we evaluated the PediEAT 9–12 months 15 10 25
alongside a previously established measure, the Mealtime Behavior 12–15 months 29 15 44
Questionnaire (MBQ) (14). The MBQ measures problematic beha- 15–18 months 17 19 36
viors during mealtime of young children aged 2 to 6 years with 33 18–24 months 35 27 62
items that were factored with a community sample. The 4 subscales 24–30 months 27 32 59
(Food Refusal/Avoidance, Food Manipulation, Mealtime Aggres- 30–36 months 24 21 45
sion/Distress, and Choking/Gaging/Vomiting) had internal consis- 3–4 years 49 34 83
tencies ranging from 0.76 to 0.89. Parents are asked to ‘‘. . . rate 4–5 years 34 34 68
each behavior as it occurred during mealtimes or feeding over the 5–6 years 36 21 57
past week’’ (p. 145) (14) and to select from 5 response options for 6–7 years 37 29 66
each item, with 3 options provided representing the tails and center Total 312 255 567
(Never, Sometimes, Always).

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JPGN  Volume 66, Number 2, February 2018 The Pediatric Eating Assessment Tool

TABLE 2. Descriptive statistics for respondents and target children Factor Analysis
(n ¼ 567)
An exploratory factor analysis was run on the remaining 90
Variable Frequency items using principal components analysis with varimax rotation.
Examination of the scree plot revealed that a 4- to 7-factor solution
Relationship to Child
would appropriately represent the data. We systematically tested a
Mother 95.2%
7-, 6-, 5-, and 4-factor solution, each time examining the total
Father 3.9%
variance explained, the added variance explained by the addition of
Other 0.9%
a higher number of factors, cross-loading of items, and the concep-
Race (n ¼ 564)
tual clarity of the derived factors. Through a process of eliminating
White 84.4%
1 item at a time based on communalities, and re-examining the
Black 4.4%
factor solutions, it was determined that a 4-factor structure, with 83
Multi-racial 4.1%
items, was the best solution. We then conducted a conceptual
Asian 3.7%
analysis of each item within each of the 4 factors to determine
Hispanic 2.7%
placement of cross-loaded items and elimination of items with low
Other 0.7%
loadings. This process led to movement of 3 items from 1 factor to a
Household Income (n ¼ 559)
cross-loaded factor, and deletion of a total of 5 items. All remaining
<$20,000 4.1%
items loaded above 0.33. The final 4 factors, with a total of 78 items,
$20–$39,999 12.3%
explained 39.4% of the total variance; factor loadings for the rotated
$40–59,999 11.6%
solution are displayed in Table 3.
$60–79,999 17.7%
Factor 1 contains 27 items representing physiologic symp-
$80–99,999 16.1%
toms related to eating or mealtime, such as breathes faster or harder
>$100,000 38.1%
when eating, arches back during or after meals, and throws up
Education
during mealtime. Factor 2 contains 23 items representing problem-
High School degree or less 9.2%
atic mealtime behaviors, such as insists of being fed by the same
Technical School/Community College 11.3%
person, becomes upset by the smell of food, and refuses to eat.
College/University 79.5%
Factor 3 contains 15 items representing selective/restrictive eating,
Family Type
such as will eat mixed textured food, will eat foods that need to be
Two-parent 90.3%
chewed, and will eat frozen food, like ice cream. Factor 4 contains
Single-parent 7.6%
13 items representing oral processing, such as puts too much food in
Other 2.1%
mouth at 1 time, has to be reminded to chew, and prefers smooth
Parent reports child has feeding problem
foods like yogurt.
Yes 42.0%
Unsure 12.7%
Internal Consistency Reliability
No 45.3%
Diagnosed feeding problem 34.4% Cronbach’s coefficient alpha (a) was used to assess internal
Currently supplements with feeding tube 12.7% consistency reliability of the total PediEAT and the subscales. The
Child has seen a professional in the past 41.1% total PediEAT had excellent internal consistency (a ¼ 0.95) and the
6 months for feeding issues 4 subscales had excellent to good internal consistencies (a ¼ 0.92,
Select child conditionsy 0.91, 0.84, 0.84; respectively).
History of prematurityz 25.0% All factors, hereafter called subscales, and total PediEAT
Developmental delay§ 23.4% scores were significantly correlated (r ¼ 0.70–0.83, P < 0.001).
Sensory processing disorderjj 13.6% The Physiologic Symptoms subscale was most strongly correlated
Genetic disorderjj 10.7% with the total score. Moderate positive correlations existed between
Congenital heart diseasejj 9.8% the subscale scores (r ¼ 0.32–0.61, P < 0.001); Physiologic Symp-
Cerebral palsyjj 7.0% toms was most related to Selective/Restrictive Eating; Problematic
Autism spectrum disorderjj 5.5% Mealtime Behaviors was least related to Oral Processing.
n ¼ 544; ymore than one condition could be selected; n ¼ z556, §561,
jj
543. Construct Validity
The PediEAT total scores were strongly related to the MBQ
total scores (r ¼ 0.77, P < 0.001, n ¼ 466), establishing construct
Item Analysis validity. The PediEAT subscale scores were moderately to strongly
related to the MBQ total scores (r ¼ 0.46–0.77, P < 0.001) with the
Descriptive statistics and item-total and inter-item correla- Problematic Mealtime Behaviors subscale of the PediEAT most
tions (r, Pearson’s product-moment correlation) were calculated strongly related to the MBQ total scores. Weak to strong positive
for each of the items. No single PediEAT item was identified as correlations existed between the PediEAT and the MBQ subscale
having more than 10% missing data so all were retained. Seven scores (r ¼ 0.26–0.81, P < 0.001).
items were removed from further analysis due to correlations Total PediEAT and subscale scores were compared for a
of >0.8 (3 items) or <0.3 (4 items). All remaining items correlated subset of the sample with and without feeding problems using
at least moderately with other items. The Kaiser-Meyer-Olkin independent-samples t tests. For this ‘‘known groups’’ validity
statistic was 0.914, indicating an adequate sample size (18) analysis, the feeding problem group was defined as parent-report
and the Bartlett test of sphericity was statistically significant of child having a diagnosed feeding problem (n ¼ 187). The no
(x2 ¼ 22,525.97, P ¼ 0.000), indicating the sample was suitable feeding problem group was defined as parent report of no feeding
for factoring (19). problem, no diagnosed feeding problem, no use of feeding services

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Thoyre et al JPGN  Volume 66, Number 2, February 2018

TABLE 3. Factor loadings for principal component analysis with varimax rotation of the Pediatric Eating Assessment Tool Scales

Subscale Pediatric Eating Assessment Tool Items Factor loadings

Physiologic symptoms; 27 items; Gets watery eyes when eating 0.71

Cronbach’s a 0.92 Gets red color around eyes or face when eating 0.65
Gets pale or blue color around his/her lips during meals 0.64
Coughs during or after eating 0.63
Sounds gurgly or like they need to cough or clear their throat during or after eating 0.62
Breathes faster or harder when eating 0.60
Throws up between meals (from 30 minutes after the last meal until the next meal) 0.59
Sounds different during or after a meal (eg, voice becomes hoarse, high-pitched, or quiet) 0.59
Needs to take a break during the meal to rest or catch their breath 0.58
Sweats/gets clammy during meals 0.58
Arches back during or after meals 0.56
Throws up during mealtime 0.56
Gags when it is time to eat (eg, when they see food or when placed in high chair) 0.55
Burps more than usual while eating 0.55
Moves head down toward chest when swallowing 0.55
Has food or liquid come out of nose when eating 0.53
Gags with smooth foods like pudding 0.53
Tilts head back while eating 0.50
Chokes or coughs on water or other thin liquids 0.48
Gags, coughs, or vomits when brushing teeth 0.47
Gets a bloated tummy after eating 0.45
Drools when eating 0.41
Has a hard time eating due to stuffy nose 0.41
Turns red in face, may cry with stooling 0.40
Gags with textured food like coarse oatmeal 0.40
Gets tired from eating and is not able to finish 0.39
Has gas 0.33
Problematic mealtime behaviors; Avoids eating by playing or talking 0.78
23 items; Cronbach’s a 0.91 Has to be reminded to keep eating 0.74
Stops eating after a few bites 0.70
Won’t eat at meals, but wants food later 0.70
Has to be told to start eating 0.68
Likes to eat 0.67
Refuses to eat 0.63
Shows more stress during meals than during non-meal times (whines, cries, gets angry, tantrums) 0.63
Eats a variety of foods (fruits, vegetables, proteins, etc) 0.56
Is willing to stay seated during mealtime 0.55
Likes something 1 day and not the next 0.55
Insists on food being offered in a certain way (such as, how food is on the plate or what dish or 0.53
spoon is used, or where they sit)
Becomes upset by the smell of food 0.50
Opens their mouth when food is offered 0.49
Throws food or pushes food away 0.47
Prefers to drink instead of eat 0.47
Eats better when entertained 0.41
Takes more than 30 minutes to eat 0.40
Prefers crunchy foods 0.39
Insists on being fed by the same person (s) 0.38
Is willing to touch food with their hands 0.37
Needs mealtime to be calm 0.36
Wants the same food for more than 2 weeks in a row 0.36
Selective/restrictive eating; 15 items; Will eat foods that need to be chewed 0.78
Cronbach’s a 0.84 Will eat mixed textured foods 0.64
Is willing to feed self (if younger in age, holds cup, feeds self-crackers) 0.64
Chews their food enough 0.59
Will eat frozen food, like ice cream 0.56
Will eat textured food like coarse oatmeal 0.55
Moves food in their mouth for chewing without help 0.55
Keeps food in mouth when eating (food means non-liquids) 0.54
Keeps liquids in mouth when drinking 0.50
Keeps their tongue inside mouth during eating 0.49

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JPGN  Volume 66, Number 2, February 2018 The Pediatric Eating Assessment Tool

TABLE 3. (Continued)

Subscale Pediatric Eating Assessment Tool Items Factor loadings

Will eat food warmer than room temperature 0.48

Acts hungry before meals 0.47
Sniffs food or objects 0.42
Eats too fast 0.39
Spits food out 0.38
Oral Processing; 13 items; Stores food in their cheek or roof of mouth 0.67
Cronbach’s a 0.84 Has to be reminded to chew food 0.65
Gets food stuck in their cheek or roof of mouth 0.63
Sucks on food to soften or moisten it, rather than chewing it 0.62
Puts too much food in mouth at 1 time 0.53
Chews food but does not swallow it 0.49
Prefers smooth foods like yogurt 0.49
Puts fingers in mouth to move food 0.41
Prefers strong flavors 0.40
Bites down on the spoon or fork and does not release it easily 0.39
Chews on toys, clothes or other objects 0.39
Chews a bite of food for a long time (30 seconds or longer) 0.38
Grinds teeth when awake 0.34

in the past 6 months, and no use of a feeding tube (n ¼ 220). Total In this study, the factor structure of the PediEAT was
PediEAT scores were significantly higher (ie, more feeding prob- examined with an adequate size sample of parents caring for
lem symptoms) for the diagnosed feeding problem group children with and without feeding problems. Target children
(M ¼ 135.3, SD ¼ 38.4) compared with the no feeding problem were distributed across the intended age ranges of the instrument
group (M ¼ 72.7, SD ¼ 26.5); t(322) ¼ 18.79, P < 0.001. Levene’s and over-represented by children with parent report of feeding
test indicated unequal variances (F ¼ 23.56, P < 0.001), so degrees problems, thereby increasing the likelihood of characterizing a
of freedom were adjusted from 405 to 322. All 4 PediEAT subscale wide range of feeding symptoms. For those with reported feeding
scores were also significantly higher for children with a diagnosed difficulties, the severity varied; 12.7% of parents reported their
feeding problem from those without, P < 0.001; degrees of freedom child required supplemental tube feedings while an equal percent
were adjusted for all tests (Fig. 1). We examined differences reported being unsure of whether their child had a feeding
between the 2 groups in categories of income, education and problem. The children with parent report of diagnosed feeding
selected child conditions using the non-parametric Mann-Whitney problems had a variety of conditions, with one-half reported as
U test. Income level was greater for the no feeding problem group developmentally delayed. This is similar to Berlin et al’s feeding
(Mdn ¼ $80–99,999/year) compared with the feeding problem clinic sample (20). The wide range of characteristics of the target
group (Mdn ¼ $60–79,999/year), U ¼ 15229, P < 0.001. Education children strengthens the validity of the factor analysis and
level was also greater for the no feeding problem group supports the relevance of the PediEAT across many clinical
(Mdn ¼ Technical School/Community College for both groups), populations.
U ¼ 17,688, P ¼ 0.001. All child health conditions occurred signif- The PediEAT’s factor solution was derived through an
icantly more often in the feeding problem group compared with the iterative process of principal components analysis resulting in 78
no feeding problem group (P < 0.001): 37.6% versus 13.2% pre- items represented by 4 subscales: Physiologic Symptoms, Problem-
maturity, 50.5% versus 1.8% developmental delay, 27.4% versus atic Mealtime Behaviors, Selective/Restrictive Eating, and Oral
0.9% sensory processing disorder, 26.9% versus 1.4% genetic Processing. Based on the time to complete the 97-item retest of the
disorder, 20% versus 3.6% congenital heart disease, 12% versus PediEAT, we estimate the 78-item version would take 10 to 12
2.7% cerebral palsy, and 8.6% versus 0.9% autism spectrum minutes to complete.
disorder. The Physiologic Symptoms subscale was the largest factor
with 27 items and explained the greatest amount of the variance
Temporal Stability (22.2%) of the 4 subscales. Adding physiologic symptoms to
feeding assessment is unique among feeding assessment instru-
The PediEAT’s total and subscales scores at baseline and ments. Symptoms of gastroesophageal reflux, abdominal distention,
2 weeks later were strongly correlated (r ¼ 0.87–0.95, P < 0.001, vomiting, and constipation have been found to be associated with
n ¼ 97), demonstrating good to excellent test-retest reliability. selective eating, food refusal, dysphasia, lower caloric intake, and/
or delayed feeding skills (21–24). With the exception of the MBQ’s
3-item Choking/Gagging/Vomiting subscale and 2 similar items on
DISCUSSION the Toddler Refusal-Texture subscale of the Behavioral Pediatric
The PediEAT has been systematically developed and content Feeding Assessment Scale (25), feeding assessment instruments
validated to measure a broad range of behavioral and physiologic with adequate psychometric properties have primarily focused on
symptoms of feeding problems in young children aged 6 months to behavioral symptoms of feeding problems with little to no attention
7 years who are eating at least some solid foods (13). The PediEAT to physiologic constraints on eating. The PediEAT’s physiologic
is a parent-report instrument, recognizing that parents are the most symptoms subscale increases the comprehensiveness of feeding
ecologically valid reporters of their child’s day-to-day symptoms. assessment.

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Thoyre et al JPGN  Volume 66, Number 2, February 2018

180.0

160.0

Feeding Problem (n=187)

140.0
135.3 No Feeding Problem (n=216)

120.0

100.0

80.0

72.7
60.0

50.4
40.0

29.9 31.9
29.2
20.0 23.7
16.7 14.4
11.7
0.0
Total Phyiologic Problematic Selective/ Oral
PediEAT* Symptoms* Mealtime Restrictive Processing*
Behaviors* Eating*

FIGURE 1. Comparison of Pediatric Eating Assessment Tool (PediEAT) Total and Subscale scores of children with and without parent-reported

diagnosed feeding problems. Error bars represent 1 standard deviation. P < .001.

The PediEAT is valid for children as young as 6 months of Limitations

age and has now been tested through the age of 7 years. Few
instruments assessing symptoms of feeding problems have been Parent report of child feeding diagnosis, used to define the
validated for children between 6 and 24-months of age. Identifying feeding problem group in the known group validation analysis, was
feeding problems early, before the establishment of avoidant not confirmed by medical record. Therefore, caution is required in
behavioral patterns is necessary for selection of interventions that interpreting the group data. More research is needed to examine the
are optimally timed and targeted to underlying problems. The 6- to sensitivity and specificity of the PediEAT in identifying children
18-month-age period is particularly critical for assessment of the with and without feeding problems. Of note, children with diag-
child’s transition to foods that increase in taste and texture com- nosed feeding problems were more likely to live in homes with
plexity as this process contributes to oral motor skill development lower income and less educated parents. Parents of children with
(26,27), and when delayed, has been found to be associated with feeding problems have identified significant family consequences
more feeding problems (28,29). Several studies retrospectively of pediatric feeding problems that deserve more attention. Limited
report early onset of feeding problems with samples derived from access to competent feeders in child care settings and inability of
feeding specialty clinics. Rommel et al (30) reported 50% of their children to eat adequately outside the home has negative conse-
sample presented with feeding problems before 1 year of age and quences for parental work or pursuit of higher education (32). More
Williams et al (31) reported 75% of their sample had onset of the is to be learned about how to best support families with children
feeding problem before 18 months of age. Meyer et al (24) reported with feeding problems.
the median age of onset of symptoms of food protein-induced Further research is also needed to examine the impact of
gastrointestinal allergies was 5 months, whereas first appointment child age on the symptom profiles of young children with feeding
to a specialist was at a median age of 5 years. Feeding problems problems. Given the normative age for the development of chewing
were reported by 40% of these parents and were documented in the begins at a mean age of 9 months (33), a limitation of the PediEAT
medical records of 30%, with significantly more early physiologic at present is lack of sensitivity of the scoring system to expected
symptoms of bloating, vomiting, rectal bleeding, and constipation differences in scoring at the lower age range. To address this, norm
associated with feeding problems. They suggested poor recognition referencing with typically developing children without feeding
of significant early symptoms contributed to the delay in referral for problems is underway to examine the performance of individual
specialist care. items across the ages of 6 months to 7 years. Norm referencing will

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JPGN  Volume 66, Number 2, February 2018 The Pediatric Eating Assessment Tool

establish cut points for normative subscale scores by age, thereby 9. Crapnell TL, Rogers CE, Neil JJ, et al. Factors associated with feeding
strengthening the interpretation of the PediEAT scores. A compan- difficulties in the very preterm infant. Acta Paediatr 2013;102:e539–45.
ion tool developed for the newborn age through 6 months, the 10. Marshall J, Hill RJ, Ware RS, et al. Clinical characteristics of 2 groups of
Neonatal Eating Assessment Tool (NeoEAT), has been content children with feeding difficulties. J Pediatr Gastr Nutr 2016;62:161–8.
validated (34); the factor analysis and norm referencing will be 11. Thoyre SM, Pados BF, Park J, et al. Development and content validation
available soon. Together, the NeoEAT and PediEAT will allow of the Pediatric Eating Assessment Tool (Pedi-EAT). Am J Speech Lang
Pathol 2014;23:46–59.
tracking of feeding difficulties from birth through age 7 with a 12. Geoffrey RS, Cynthia B, Graham AB 3rd et al. 2014 recommendations
consistently developed set of tools. for pediatric preventive health care. Pediatrics 2014;133:568–70.
13. DeVellis RF. Scale Development: Theory and applications. 3rd ed.
CONCLUSIONS Thousand Oaks, CA; 2012.
The PediEAT is a valid and reliable instrument for assess- 14. Berlin KS, Davies WH, Silverman AH, et al. Assessing children’s
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iEAT’s content was comprehensively validated with all potential University Press, Inc; 2015.
users, thereby creating a strong platform for further psychometric 16. DeVet HCW, Terwee C, Mokkink LB, et al. Measurement in Medicine:
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of the PediEAT, identifying 4 subscales for future use. We have 17. U.S. Census Bureau. Median household income (in 2015 dollars),
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stability was presented. Norm referencing of the PediEAT will 20. Berlin KS, Lobato DJ, Pinkos B, et al. Patterns of medical and
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sites through which participants were recruited: The North hardness. Appetite 2016;100:263–71.
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academic institutions and supported by the US National Institutes of gastro-oesophageal reflux disease: a controlled study. J Paediatr Child
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program. Join the Conquest is a community of volunteers created by 24. Meyer R, Rommel N, Van Oudenhove L, et al. Feeding difficulties in
The North Carolina Translational & Clinical Sciences Institute (NC children with food protein-induced gastrointestinal allergies. J Gastro-
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from Dr. Mary Lynn. 26. Mason SJ, Harris G, Blissett J. Tube feeding in infancy: Implications for
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