Childhood picky eating behaviour and its impact on

the growth of young children: A scoping review

Nurshazwani Ahmad Nazri, BSc. *Nurul Hazirah Jaafar, PhD

Department of Nutrition Sciences, 1Food Security and Public Health Nutrition Research
Kulliyyah of Allied Health Sciences, Group (FOSTER),
International Islamic University Malaysia, 2Department of Nutrition Sciences,

Jalan Sultan Ahmad Shah, Kulliyyah of Allied Health Sciences,

Bandar Indera Mahkota, International Islamic University Malaysia,
25200 Kuantan, Pahang Jalan Sultan Ahmad Shah,
[email protected] Bandar Indera Mahkota,
25200 Kuantan, Pahang
[email protected]

Suriati Zakaria, BSc. Wan Azdie Mohd Abu Bakar, PhD

1Food Security and Public Health Nutrition Research
Unit Pemakanan, Pejabat Kesihatan Daerah
Kuantan, Jalan Tengku Muhammad, Alor Akar, Group (FOSTER),
2Department of Nutrition Sciences,
25050 Kuantan, Pahang, Malaysia.
[email protected] Kulliyyah of Allied Health Sciences,
International Islamic University Malaysia,
Jalan Sultan Ahmad Shah,
Bandar Indera Mahkota,
25200 Kuantan, Pahang
[email protected]

Nuraniza Azahari, PhD Syifak Izhar Hisham, PhD

1Food Security and Public Health Nutrition Faculty of Computing, Universiti Malaysia Pahang,
Research Group (FOSTER), 26600 Pekan, Pahang, Malaysia.
2Department of Nutrition Sciences, [email protected]
Kulliyyah of Allied Health Sciences,
International Islamic University Malaysia, Siti Sabariah Buhari, PhD
Jalan Sultan Ahmad Shah, Centre of Nutrition and Dietetics,
Bandar Indera Mahkota, Faculty of Health Sciences,
25200 Kuantan, Pahang Universiti Teknologi Mara (UiTM),
[email protected] Cawangan Selangor,
Kampus Puncak Alam,
42300 Puncak Alam, Selangor
[email protected]
*Corresponding author: Nurul Hazirah Jaafar, Article History:
[email protected] Received on August 9, 2023
Accepted on January 12, 2024
Published on January 31, 2024

Abstract:

Background: Malnutrition occurs due to inadequate food intake and low daily energy intake, often
associated with picky eating behaviour (PEB). Picky eaters have limited food choices and poor dietary
diversity, leading to malnutrition. Therefore, this article aims to explore the impact of childhood eating
behaviour on a young child's growth. Method: Articles were identified through six electronic search engines
using 12 keywords. Articles were included if they met the following criteria: (1) sample of study involved
 Childhood picky eating behaviour and its impact on the growth...

young children (below six years old); (2) study outcome focusing on the impact of eating behaviour on the
growth of the children (3) published in English. Studies were excluded if they were review articles, qualitative
studies, and involved children with clinical health problems. Result: A total of 413 articles were screened,
and 8 full-text articles were evaluated. The prevalence rates of selective eaters varied greatly from 25% in
India to 77% in Iraq. The screening tools used for identifying PEB varied, with the Children’s Eating
Behaviour Questionnaire (CEBQ) being the most commonly used tool. Short-term implications of PEB on
children include the risk of poor diet intake and limited consumption of a variety of food groups, which can
lead to adverse health outcomes. Meanwhile, long-term implications include the development of eating
disorders in adulthood. Conclusion: Our findings reveal that PEB has had a significant impact on the growth
of young children. Despite the increasing concern about the implications of PEB, there is a lack of sufficient
research studies on the effects of this behaviour on the nutritional status of young children.

Keywords: eating behaviour; picky eaters; nutritional status; growth; young children

Introduction:
Proper nutrition is essential throughout the different status. These modifiers include the types of foods
stages of life. In the case of infants, exclusive offered to the child, parenting styles, breastfeeding,
breastfeeding is recommended for the first six months, and complementary feeding. Such a review will help
followed by the introduction of complementary shed light on the topic and provide valuable insights.
feeding up to two years of age (World Health Therefore, this review aims to explore the effects of
Organization (WHO), 2021; National Coordinating childhood eating behaviour on a child's growth.
Committee on Food and Nutrition, 2010). The age
group of 0-5 years is particularly critical for ensuring
optimal nutrition to support growth and good health Methodology:
in children. However, global efforts to improve
nutrition quality and prevent undernutrition in young The protocol of this scoping review was chosen due to
children are still challenging. The double burden of emerging evidence on childhood PEB and its impact
malnutrition, encompassing underweight, stunting, on the growth of young children, whilst still ensuring
wasting, and obesity (WHO, 2016), contributes to a rigorous and transparent method for mapping
nearly half of all deaths in children under 5 worldwide (Arksey & O’Malley, 2005). The reporting adheres to
(United Nations Children's Fund (UNICEF), 2022). the five-stage framework by Arksey & O’Malley
(2005), incorporating the checklist from the Preferred
Undernutrition often arises due to insufficient food Reporting Items for Systematic Reviews and Meta-
intake and low daily energy intake (WHO, 2016; Analyses (PRISMA) extension for scoping reviews
Norliza et al., 2021; Mok et al., 2022), and picky eating (Tricco et al., 2018).
behaviour (PEB) may play a role in this context.
Individuals with PEB exhibit restricted food selection
and limited dietary variety, which can lead to Stage 1: Identify the Research Questions
malnutrition (Hikmah & Nur Islami, 2022; Mok et al., The research questions used to guide the search
2022). Food neophobia and picky eating are common strategy include: 1) What tools or methods have been
behaviours observed during children's growth and used to identify young children with picky eating?
development. Food neophobia refers to the rejection and 2) What is the impact of eating behaviour towards
of new foods, while PEB involves inadequate nutritional status among young children? The studies
consumption of both familiar and unfamiliar foods were then further evaluated by referring to the guided
(Dovey et al., 2008). While picky eating is not a research questions and eligibility criteria.
medical term and encompasses a wide range of
behaviours, it can negatively impact a child's diet
quality and restrict the consumption of diverse food Stage 2: Identifying Relevant Studies
groups, leading to adverse health outcomes. It is Various databases such as PubMed, Science Direct,
crucial to review how researchers define picky eating, EBSCO (Medline), Scopus, Google Scholars, and
determine the prevalence of picky eaters, and identify ProQuest were searched to select studies from 2017 to
potential effect modifiers that could impact the February 2023. There were no restrictions imposed on
association between eating behaviours and weight the study design and publication status. In total, 8
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 Childhood picky eating behaviour and its impact on the growth...

articles were critically reviewed. The search terms Table 1: PICOS criteria for inclusion and exclusion of
used were "Picky" (picky, fuss*, choosy, selective) studies
AND "Growth" (body weight, nutrition*, nutritional
status) AND "Child" (child*, young child*, paediat*, Category Inclusion Exclusion
pediat*, todd*). Participants Children aged 0– Children with
6 years old. chronic illnesses
Stage 3: Study Selection or special
Research articles were evaluated using the PICOS nutritional
(Population, Intervention, Comparators, Outcome, needs that will
and Study Design) model (Table 1) (Liberati et al., impact their
2009). The following studies were included if they met dietary
the following criteria: (1) sample of study involved diversity.
young children (below six years old); (2) study
outcome focusing on the impact of eating behaviour Intervention None None
on the growth of the children (3) published in English.
Studies were excluded if they were review articles, Comparator Prevalence of None
qualitative studies and involved children with clinical PEB.
health problems such as autism, down syndrome, Screening tools.
dyslexia, global development delay (GDD) or health Association
problem interfering with eating habits. between PEB
and young
Figure 1 shows the modified PRISMA flow diagram children’s
that provides an overview of the process for selecting nutritional
articles. Initially, 413 records were screened and 131 status.
duplicates were removed. Out of the remaining 282
articles, only ten were relevant to the study topic. Two Outcomes Determination None
reports lacked full articles and were excluded. of PEB.
Therefore, eight publications were included that Nutrition-
focused on the association between eating behaviour related outcomes
and nutritional status in young children. such as
anthropometric
measurements
(body mass
index, waist
circumference),
dietary intakes,
or dietary
diversity score.

Study Cross-sectionals, Review articles.

design mixed-method, Qualitative
randomized studies.
controlled trials,
pre-post design
quasi-
experimental
studies.

Stage 4: Charting the Data

The main author conducted a thorough search,
screening the articles for both quality and relevance
based on the established criteria and research
question. Meanwhile, the other reviewers
Figure 1: PRISMA Flow Diagram independently analyzed each paper and recorded key
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 Childhood picky eating behaviour and its impact on the growth...

details such as the author, year of publication, location eating behaviour and nutritional status outcomes in
of the study, study design, study population, study their respective study populations.
size, screening tools used to identify picky eating, and
the outcomes/findings of child behaviours associated
with picky eating. Screening tools for PEB
The identification of picky eaters in the studies
Stage 5: Collating, Summarising and Reporting involved the use of various screening tools. In total,
Results nine studies employed four different tools and
After screening several studies, eight of them were utilized a total of 14 scales, as summarized in Table 2.
deemed relevant and selected for further analysis. The The CEBQ by Wardle et al. (2001) was the most used
authors reviewed these eight publications and tool, accounting for 75% (n=6) of the studies (Hikmah
extracted the data into a spreadsheet (Table 2). The & Nur Islami, 2022; Yaqob Qazaryan & Kazim Karim,
findings were then independently analyzed by all 2019; Chao, 2018; Tan et al., 2022; Derks et al., 2018;
authors, who identified the factors associated with Shettiwar & Wade, 2019).
PEB and its impact on nutritional status. These factors
were characterized to help develop successful The remaining 25% (n=2) of the studies employed
interventions, and the results were presented in a different screening tools, including self-administered
supplementary table. Finally, the authors discussed surveys (Kwon et al., 2017), a modified version of the
the findings, and a consensus was reached. United Kingdom Department of Health Survey of the
Diets of British School Children (UKSQ) (Chao, 2018),
and Stanford Feeding Questionnaire (SFQ) on Child-
Parent Feeding Behavior (Kumar et al., 2018). Despite
Results: the variation in tools used, all eight studies relied on
parental reports regarding their children's picky
Study Characteristics eating behaviour.
The selected studies had various characteristics, as
shown in the Supplementary table. This review
Association of Eating Behaviour and Nutritional
includes seven cross-sectional studies (mentioned in
Status Among Young Children
the seven citations) and one cohort research (Derks et
As shown in the Supplementary Table, all eight
al., 2018). The participants' ages ranged from 12
articles indicated a significant association (p<0.05)
months (Kwon et al., 2017; Shettiwar & Wade, 2019;
between PEB and the nutritional status of young
Kumar et al., 2018) to 6 years old (Kumar et al., 2018;
children. These associations were observed in various
Hikmah & Nur Islami, 2022; Derks et al., 2018), and
parameters, including weight-for-age (WAZ), height-
the sample sizes ranged from 192 (Hikmah & Nur
for-age (HAZ), and body mass index (BMI)-for-age
Islami, 2022) to 3,331 children (Derks et al., 2018). In
(BAZ). Specifically, the studies consistently
total, these eight articles had 7,196 participants.
demonstrated that picky eaters had significantly
Most studies on eating behaviour (87.5%; n=7) were lower z-scores in WAZ, HAZ, and BAZ compared to
found in Asia, specifically Malaysia, Iraq, India, non-picky eaters (p<0.05) (Hikmah & Nur Islami,
Taiwan, Vietnam, and Singapore. While only a small 2022; Tan et al., 2022; Yaqob Qazaryan & Kazim
portion of the study (12.5%, n=1) was completed in the Karim, 2019; Derks et al., 2018; Shettiwar & Wade,
Netherlands. 2019; Chao, 2018; Kumar et al., 2018; Kwon et al.,
2017). Overall, the studies revealed that the picky eater
group had lower z-score values below the median (z-
Prevalence of Picky Eating Behaviour score 0) for WAZ, HAZ, and BAZ compared to the
The prevalence of picky eaters varied across different WHO Child Growth Standards (2016).
studies, as presented in Table 1. Reported prevalence
rates ranged from 25% in India (Shettiwar & Wade,
2019) to 77% in Iraq (Yaqob Qazaryan & Kazim Karim,
2019). Additionally, Kumar et al. (2018) reported age- Discussion:
specific prevalence, revealing an increase in PEB from Prevalence of Picky Eating Behaviour
32% to 69% as age increased. However, two articles The key findings of this scoping review pertain to the
(Derks et al., 2018; Tan et al., 2022) did not provide prevalence of picky eating, the diverse screening tools
data on the prevalence of picky eaters. Instead, they employed to identify picky eaters, and the association
focused on examining the association between picky between eating behaviour and nutritional status in

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 Childhood picky eating behaviour and its impact on the growth...

Table 2: Instruments and scales used in determining PEB

Author (year) Screening Tools n (%)

1. Food responsiveness/ length of time for each meal and eating activities
Hikmah & Nur Islami (2022), Yaqob
Qazaryan & Kazim Karim (2019), Chao
(2018), Tan et al. (2022), Derks et al (2018), CEBQ 6 (75.0)
and Shettiwar & Wade (2019)

2. Emotional overeating
Hikmah & Nur Islami (2022), Yaqob
Qazaryan & Kazim Karim (2019), Chao
(2018), Tan et al. (2022), Derks et al (2018), CEBQ 6 (75.0)
and Shettiwar & Wade (2019)

3. Food preferences/ high selective intake

Hikmah & Nur Islami (2022), Yaqob
Qazaryan & Kazim Karim (2019), Chao
(2018), Tan et al. (2022), Derks et al (2018), CEBQ
and Shettiwar & Wade (2019) 7 (87.5)

Chao (2018) Modified version of UKSQ

Kumar et al. (2018) SFQ

4. Desire to drink
Hikmah & Nur Islami (2022), Yaqob
Qazaryan & Kazim Karim (2019), Chao
(2018), Tan et al. (2022), and Shettiwar & CEBQ 4 (50.0)
Wade (2019)

5. Satiety responsiveness
Hikmah & Nur Islami (2022), Yaqob
Qazaryan & Kazim Karim (2019), Tan et al.
(2022), Derks et al (2018), and Shettiwar & CEBQ 5 (62.5)
Wade (2019)

6. Slowness in eating
Hikmah & Nur Islami (2022), Yaqob
Qazaryan & Kazim Karim (2019), Tan et al. CEBQ 4 (50.0)
(2022), and Shettiwar & Wade (2019)

7. Emotional undereating
Hikmah & Nur Islami (2022), Yaqob
Qazaryan & Kazim Karim (2019), Tan et al. CEBQ 4 (50.0)
(2022), and Shettiwar & Wade (2019)

8. Food fussiness/ refusal of specific food groups

Hikmah & Nur Islami (2022), Yaqob
Qazaryan & Kazim Karim (2019), Tan et al.
(2022), and Shettiwar & Wade (2019) CEBQ 5 (62.5)

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 Childhood picky eating behaviour and its impact on the growth...

Kwon et al. (2017) Self-administered survey

9. Specific food preparation methods

Kwon et al. (2017) Self-administered survey 1 (12.5)

10. Eating a small amount/ number of meals, diversity and amount of food consumed per day
Kwon (2017) Self-administered survey 2 (25.0)

11. Emotional or behaviors/ eating behaviors

Chao (2018) Modified version of UKSQ 2 (25.0)

12. Neophobic behavior/Fear of feeding

Kwon et al. (2017) Self-administered survey
2 (25.0)
Kumar et al. (2018) SFQ

13. Enjoyment of food

Hikmah & Nur Islami (2022), Yaqob
Qazaryan & Kazim Karim (2019), Chao
(2018), Tan et al. (2022), Derks et al (2018), CEBQ 6 (75.0)
and Shettiwar & Wade (2019)

14. Parental misperception

Kumar et al. (2018) SFQ 1 (12.5)

young children. Currently, there is no standardized Most of the studies reported on the scoring of the
definition of picky eating, nor is there a universally assessment tools used to assess eating style in
accepted and well-defined assessment method (Taylor children. For the CEBQ, a self-administered
& Emmett, 2019). The prevalence of picky eaters questionnaire by Kwon et al. (2017), eating style is
varied widely across studies and can be attributed to assessed based on the level of scoring. Meanwhile,
differences in study designs, assessment tools, and Chao (2018) has not reported on the clinical
sociocultural factors employed in various studies. practicability and scoring implications for the
Additionally, this review identified that the age at Modified version of UKSQ. Thus, even though PEB
which children develop persistent picky eating has been considered a complex behaviour, the
behaviour may vary. Yaqob Qazaryan & Kazim Karim accurate definition, assessment, and standardized
(2019) observed the highest prevalence of picky eaters method to identify PEB is not yet established.
emerging at 36 months of age. These findings align
with a previous systematic review by Fitriana et al. Association of Eating Behaviour and Nutritional
(2019) and Taylor & Emmett (2019), which indicated Status Among Young Children
that the peak prevalence of picky eating occurs at Children can exhibit picky eating behaviour due to
about age 3 years and remains stable with increasing various factors, including food and drink colour
age. At this age, the children were picky as they were preferences (Kumar et al., 2018), taste perception
reflecting on the parental feeding styles in response to (Keller et al., 2002; Petty et al., 2020), food texture
increased child autonomy (Taylor & Emmett, 2019). (Kumar et al., 2018), refusal of specific food groups
(Yaqob Qazaryan & Kazim Karim, 2019; Shettiwar &
Screening tools Wade, 2019), and preferences for certain food
Similarly, we found a varying screening tool used to preparation methods (Kwon et al., 2017; Kumar et al.,
identify picky eaters among the respondents. 2018; Shettiwar & Wade, 2019). PEB affects their
However, despite the differences, all the screening dietary patterns by limiting the variety of foods
tools were answered based on parental reports about consumed, which can lead to a lower quality diet in
their children’s eating behaviour. Several of these terms of certain micronutrients and overall energy
tools have been validated. Examples include CEBQ, a intake (Norliza, 2021; Mok et al., 2022). Furthermore,
self-administered questionnaire by Kwon et al. (2017), pickiness among young children may have negative
the UKSQ, and SFQ. consequences on developmental quality, physical
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 Childhood picky eating behaviour and its impact on the growth...

activity levels, and general health status (Taylor & International Journal Social Research Methodology,
Emmett, 2019). 8:19–32. doi: 10.1080/1364557032000119616.

Chao, H. (2018). Association of Picky eating with

Limitation: growth, nutritional status, Development, Physical
activity, and health in Preschool children. Frontiers
As the selection was restricted to articles in English, in Pediatrics, 6(22). doi: 10.3389/fped.2018.00022
relevant publications in other languages may have
been missed. Besides, the determinants of picky eaters Derks, I., Sijbrands, E., Wake, M., Qureshi, F., Van Der
were varying as different studies used different Ende, J., Hillegers, M., Jaddoe, V., Tiemeier, H., &
definitions for picky eating, resulting in a wide range Jansen, P. (2018). Eating behavior and body
of picky eater prevalence and making it unclear composition across childhood: A prospective
whether this finding would hold true for everyone. cohort study 11 Medical and Health Sciences 1117
Public Health and Health Services. International
Journal of Behavioral Nutrition and Physical Activity,
Conclusion: 15 (1). doi: org/10.1186/s12966-018-0725-x

In this review, we provide insights into the prevalence Dovey, T.M., Staples, P.A., Gibson, E.L., & Halford,
of picky eaters among young children and its impact J.C. (2008). Food neophobia and “picky/fussy”
on their growth. The identification of picky eaters in eating in children: a review. Appetite, 50(2-3):181-
the studies involved the use of various screening tools 93. doi: 10.1016/j.appet.2007.09.009.
as different researchers may define PEB differently.
Dubois, L., Farmer, A.P., Girard, M., & Peterson, K.
The evidence gathered from various studies
(2007). Preschool children's eating behaviours are
consistently demonstrated that PEB had significantly
related to dietary adequacy and body weight.
impacted the growth of young children for all growth European journal of clinical nutrition, 61(7):846-55.
indicators. In conclusion, the findings from this doi: 10.1038/sj.ejcn.1602586
review emphasize the importance of addressing PEB
in children and taking immediate action to manage Fitriana, D., Pradany, R., & Rahmawati, A. (2019).
them. Interventions such as nutritional education or Correlation of Picky Eating in Children’s Growth:
guidance for parents should be developed by A Systematic Review. Jurnal Ners, 14(3). doi:
org/10.20473/jn.v14i3(si).16991
researchers and relevant organizations, including the
Ministry of Health, to improve the nutritional status
Hikmah, M.H. & Nur Islami, M.F.T. (2022). Picky
of children globally. Further research is warranted to eating behaviour and nutritional status of
explore effective strategies for addressing picky eating preschool children in Kuala Selangor, Malaysia.
and its long-term implications on health outcomes. Malaysian Journal of Medicine and Health Sciences,
18(1): 145-150.

Acknowledgement: Jacobi, C., Schmitz, G., & Agras, W.S. (2008). Is picky
eating an eating disorder. International Journal
This work was supported by the Internal Grant IIUM- Eating Disorder, 41(7):626–34.
UiTM-UMP [Grant number: SRCG20-008-0008]. doi:10.1002/eat.20545

Keller, K.L., Steinmann, L., Nurse, R.J., & Tepper, B.J.

References: (2002). Genetic Taste Sensitivity to 6-n-
Propylthiouracil Influences Food Preference and
Ahmad Fickrey, A., Alwi Muhd, H.M., Abd Aziz, A., Reported Intake in Preschool Children. Appetite,
Mohd. Shukrimi,A., & Ahmad Fadzil, A. (2021). 38: 3–12. doi.org/10.1006/appe.2001.0441
Vitamin C deficiency in a picky eater child. Med J
Malaysia, 76(5) Kumar, K.P., Srikrishna, S., Indira, P., & Eshwara, C.
(2018). Prevalence of picky eating behavior and its
Arksey, H. & O’Malley L. (2005). Scoping studies: impact on growth in preschool children.
Towards a methodological framework. International Journal of Contemporary Pediatrics,

2959
Ahmad Nazri et al. (2024) IJAHS, 8(1): 2953-2961
 Childhood picky eating behaviour and its impact on the growth...

5(3):714-719. doi: org/10.18203/2349- Pediatrics, 6(6):2444-2449. doi: org/10.18203/2349-

3291.ijcp20181036 3291.ijcp20194547

Kwon, K.M., Shim, J.E., Kang, M., Paik, & H. (2017). Tan, E., Avoi, R., Robinson, F., Jeffree, M., Abdul
Association between picky eating behaviors and Rahim, S., Ibrahim, M., Yusuff, A., & Lukman, K.
nutritional status in early childhood: performance (2022). The Association of Eating Behaviour on the
of a picky eating behavior questionnaire. Nutrients, Growth of Children from the Interior Districts of
61(7):846-55. doi: 10.1038/sj.ejcn.1602586 Sabah, Malaysia. Risk Management and Healthcare
Policy, 15: 563–570. doi: 10.2147/RMHP.S330358
Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA
statement for reporting systematic reviews and Taylor, C. M. & Emmett, P.M. (2019). Picky eating
meta-analyses of studies that evaluate health care in children: causes and consequences. Proc Nutr
interventions: explanation and elaboration. PLoS Mal J Med Health Sci, Proc Nutr Soc., 78(2):161-169.
Med., 6:e1000100. doi: 10.1017/S0029665118002586
doi:10.1371/journal.pmed.1000100
Tricco, A. C., Lillie, E., Zarin, W., O'Brien, K. K.,
Mok, K., Tung, S., & Kaur, S. (2022). Picky Eating Colquhoun, H., Levac, D., Moher, D., Peters, M. D.
Behaviour Feeding Practices, Dietary Habits, J., Horsley, T., Weeks, L., Hempel, S., Akl, E. A.,
Weight Status and Cognitive Function Among Chang, C., McGowan, J., Stewart, L., Hartling, L,
School Children in Kuala Lumpur, Malaysia. Aldcroft, A., Wilson, M. G., Garritty, C., Lewin, S.,
Malaysian Journal of Medicine and Health Sciences, Godfrey, C. M., Macdonald, M. T., Langlois, E. V.,
18(4): 10-18. doi:10.47836/mjmhs18.4.3 Soares-Weiser, K., Moriarty, J., Clifford, T.,
Tunçalp, Ö., Straus, S. E. (2018). PRISMA Extension
National Coordinating Committee on Food and for Scoping Reviews (PRISMA-ScR): Checklist and
Nutrition. (2010). Malaysian Dietary Guidelines. Explanation. Annals of Internal Medicine. ,
Kuala Lumpur: Ministry of Health. 169(7):467-473. doi: 10.7326/M18-0850. Epub 2018
Sep 4. PMID: 30178033.United Nations Children’s
Norliza, A., Zalilah. M.S., Firdaus, M., Lim, P.Y., & Lye Fund (UNICEF), World Health Organization,
M.S. (2021). Factor structure of the children’s International Bank for Reconstruction & The
eating behaviour questionnaire and its association World Bank. (2021). Levels and trends in child
with excess weight among malay school children. malnutrition: key findings of the 2021 edition of the
International Journal of Public Health and Clinical joint child malnutrition estimates. Geneva: World
Sciences, 8(5). Health Organization.

Page, M., McKenzie, J., Bossuyt, P., Boutron, I., Wardle, J., Guthrie, C. A., Sanderson, S., & Rapoport,
Hoffmann, T., Mulrow, C., Shamseer, L., Tetzlaff, L. (2001). Development of the children’s eating
J., Akl, E., Brennan, S., Chou, R., Glanville, J., behaviour questionnaire. Journal of Child Psychology
Grimshaw, J., Hróbjartsson, A., Lalu, M., Li, T., and Psychiatry, 42(7):963–970. doi:10.1111/1469-
Loder, E., Mayo-Wilson, E., McDonald, S., 7610.0079
McGuinness, L., Stewart, L., Thomas, J., …Moher,
D. (2021). The PRISMA 2020 statement: An World Health Organization (2016). Child growth
updated guideline for reporting systematic standards. https://www.who.int/tools/child-
reviews. PLOS Medicine, 18(3). growth-standards
doi.org/10.1371/journal. pmed.1003583
World Health Organization (2021, April 12).
Petty, S., Salame, C., Mennella, J.A., & Pepino, M.Y. Indicators for assessing infant and young child
(2020). Relationship between Sucrose Taste feeding practices: definitions and measurement
Detection Thresholds and Preferences in Children, methods.
Adolescents, and Adults. Nutrients, 12 (1918). doi: https://www.who.int/publications/i/item/9789
10.3390/nu12071918 240018389

Shettiwar, S. & Wade, M. (2019). Correlates of picky Wolstenholme, H., Kelly, C., Hennessy, M., & Heary,
eating behaviour in children and its effect on C. (2020). Childhood fussy/picky eating
growth. International Journal of Contemporary behaviours: a systematic review and synthesis of

2960
Ahmad Nazri et al. (2024) IJAHS, 8(1): 2953-2961
 Childhood picky eating behaviour and its impact on the growth...

qualitative studies. International Journal of Yaqob Qazaryan, K. & Kazim Karim, S. (2019). The
Behavioral Nutrition and Physical Activity, 17:2. doi: clinical link of preschoolers’ picky eating behavior
org/10.1186/s12966-019-0899-x. with their growth, development, nutritional status,
and physical activity in Iraq/Kurdistan region.
Neurol Neurosci Rep, 2:1-8. doi:
10.15761/NNR.1000115

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Ahmad Nazri et al. (2024) IJAHS, 8(1): 2953-2961
 Childhood picky eating behaviour and its impact on the growth….

APPENDIX

Supplementary table: Characteristics of the studies.

Author Study Sample Study Design Screening tools for PEB Prevalence of Outcome/ Findings
(year) Picky Eater
Hikmah & 192 children Cross-sectional Children’s Eating 31.8% Behavior assessment:
Nur Islami aged 4-5 years. Behavior Questionnaire
1. A lower degree of food responsiveness,
(2022) (CEBQ).
enjoyment of food and emotional overeating
combined with higher degree of food fussiness and
slowness in eating were prevalent among picky
eaters (p<0.05).

Association PEB and nutritional status:

1. PEB has significant association (p<0.05) with
WAZ, HAZ and BAZ.
2. More picky eaters were
underweight/stunted/wasted while more non-picky
eaters were overweight/obese.
Kwon et al. 184 children Cross-sectional Self-administered survey None Behavior assessment:
(2017) aged 1-5 years. of 21 items
1. The proportion of participants with the behavior:
“eating small amounts” (29.9%); “limited variety”
(66.9%); “preference for a specific food-preparation
method” (49.5%); “refusal to eat specific food
groups” (44.0%); and “neophobic behavior”
(32.6%).
 Childhood picky eating behaviour and its impact on the growth….

2. Older children aged 4 to 5 years showed higher

rates of “neophobic behavior” (47.5%, p = 0.0032).

Association PEB and nutritional status:

1. Picky eaters “eating small amounts” aged 4 to 5

years had significantly lower z-scores for all three
growth indices.

2. Picky eaters with “refusal of specific food

groups” were related with lower HAZ in this age
group.
Yaqob 800 children Cross-sectional Eating behavior 77% Behavior assessment:
Qazaryan & aged 2-4 years. questionnaires inspired by
1. Picky eaters were commonly:
Kazim CEBQ.
Karim Eating sweets or snacks instead of meals (52.6%);
(2019) refusing food, particularly fruits and vegetables
(37.8%); reluctant to eat regular meals (27.6%); do
not like to try new food (neophobia, 23.3%);
ingestion of specific kinds of food (16%); and
excessive drinking of milk (14.2%).

Association PEB and nutritional status:

1. Picky eaters had significantly lower average
weight-for-age, height-for-age, and BMI-for-age
percentiles.
Chao (2018) 300 children Cross-sectional Modified version of 54% Behavior assessment:
aged 2-4 years United Kingdom
Department of Health
 Childhood picky eating behaviour and its impact on the growth….

Survey of the Diets of 1. The picky eater group behavior included: being
British School Children unwilling to eat regular meals (18.5%); refusing
Questionnaire (UKSQ) food, particularly fruit and vegetables (16.7%);
(preferences for food and eating sweets or snacks instead of meals (14.8%);
food types) and CEBQ. being unwilling to try new foods (14.2%); excessive
drinking of milk (14.2%) and accepting only a few
types of food (13.6%).
2. Picky eaters did not like to eat meat (37.1%);
vegetables (38.9%); fruit (22.2%) and specific kinds
of vegetables or fruit (21.6%).
3. Significant lower number of accepted foods and
lower score in food preference were found in picky
group (15.1 ± 3.7 vs. 26.7 ± 4.1, P < 0.001; 3.0 ±
1.3 vs. 3.6 ± 1.1, P < 0.001).

Association PEB and nutritional status:

1. Compared with non-picky eaters, WAZ, HAZ,
and BAZ in picky eaters was 0.91, 0.73, and 0.44
SD lower, respectively.
2. There were significant differences of rates in the
weight-for-age, height-for-age, and BMI-for-age
percentiles <15, between picky and non-picky
eaters (P= 0.04, 0.023, and 0.005, respectively).
Tan et al. 500 children Cross-sectional CEBQ None Behavior assessment:
(2022) aged 24–59
1. “Food approach” eating behaviour were
months
positively correlated as each scale independently.
 Childhood picky eating behaviour and its impact on the growth….

2. Meanwhile, the “food avoidant” eating behaviour

demonstrated positive inter-correlations between
each scale independently.

Association PEB and nutritional status:

1. There were significant positive association
between food responsiveness, emotional overeating,
enjoyment of food with BAZ (p<0.05;
unstandardized regression coefficient: 0.17 to 0.38).
2. There were significant negative association
between satiety responsiveness, slowness of eating,
food fussiness with BAZ (p<0.01; unstandardized
degression coefficient: −0.35 to −0.36).
Derks et al. 7294 children Cross-sectional CEBQ None Behavior assessment:
(2018) recruited at
1. Non-picky eaters scores higher to food
birth but only
approaching behavior, namely: emotional
3331 children
overeating, food responsiveness and enjoyment of
at age 4 years
food, as well as the subscale satiety responsiveness.
completed the
study to the end
at 10 years old. Association PEB and nutritional status:
1. Cross-lagged models at both directions showed
that a higher BMI at the age of 4 years predicted
more food responsiveness and enjoyment of food
and less satiety responsiveness at 10 years (e.g.
satiety responsiveness: β = − 0.10, 95% CI = −
0.14, − 0.07).
 Childhood picky eating behaviour and its impact on the growth….

Shettiwar & 200 parents of Prospective CEBQ 25 % Behavior assessment:

Wade children cohort
1. Maximum age of PEB was 49 to 60 months
(2019) between 1 to 5
(38%).
years age

Association PEB and nutritional status:

1. 26% of subjects with PEB had HAZ < -3SD
(severely stunted).
2. 38% of subjects with PEB had weight-for-height
z-score (WHZ) < -3SD (severely wasted) as
compared to only 4% in non-picky eaters.
Kumar et al. 1652 parents of Cross-sectional Stanford Feeding 32.2% at 1 year Behavior assessment:
(2018) children Questionnaire (SFQ) on of age to 69.2 %
1. Two or more criteria were met to determine
between 1-6 Child- Parent Feeding at 6 years of age
picky eater, characterized by eating a limited
years age Behavior
variety of foods (94%) with strong likes (93%) and
dislikes (100%), not accepting new foods readily
(0%) and strong opinions about the preparation of
food (68%).

Association PEB and nutritional status:

1. The mean weight and height of the children is
lower in picky eaters than the non-picky eaters.