INTRODUCTION
Breastfeeding is the first programmed feeding method in humans. Changes in the diet, the feeding process, and the child’s feeding behaviors and attitudes towards food take place over time in successive stages of the child’s development. These factors affect the child’s present and future health [1]. Engaging in unhealthy eating habits during childhood can set a trajectory for adverse health outcomes, including obesity, diabetes, eating disorders, and cardiovascular diseases well into adulthood [2].
Feeding is a complex, but also a learned process that is influenced by sensory and motor development and neurological maturation in children. It is also conditioned by social and cultural factors [3]. Chewing and swallowing abilities contribute to the development of the digestive tract and enable children to explore new flavors [1]. Pediatric feeding disorders do not have a strict and commonly used definition. They are generally classified as age-inappropriate feeding difficulties that are associated with dietary, medical, and psychosocial factors and require an interdisciplinary approach [4].
Pediatric feeding disorders are generally observed between the ages of 1 and 3 years, but they can have long-lasting consequences that affect various areas of life [5]. Up to 25-50% of children in the general population experience feeding difficulties, and 10% require intensive specialist intervention. Feeding problems affect around 80% of disabled children and 40-70% of children with chronic diseases [6]. Feeding is a complex process, and feeding disorders can manifest in a wide spectrum of symptoms. Therefore, the severity of a feeding disorder should be accurately identified, and measures that are tailored to a child’s specific needs should be implemented, from short-term goals to interdisciplinary treatment. In many cases, feeding difficulties can be effectively addressed by general practitioners [6]. At present, feeding disorders are diagnosed based on the criteria presented in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the International Classification of Diseases (ICD) [7].
The aim of this study was to review the literature on the possible causes of the development of feeding disorders in children, and to highlight the influence of the family environment, including the eating habits of the parents, on the prevention, onset and therapy of feeding disorders in early age. Another important aspect of this study was to discuss practical strategies for managing feeding problems and to prepare recommendations for parents, which can be provided by a dietician.
The data for the study were collected from platforms such as Google Scholar, Science Direct, PubMed.gov, MDPI, Scopus, and Web of Science, between November 2023 and February 2024. A total of 50 references were selected out of 120 sources found using the following keywords: feeding disorders, parental nutritional practice, accessibility of food, feeding style, feeding difficulties in children, child eating behaviors, food neophobia, food intake disorders in toddlers, and children’s food refusal behaviors. The citations and keywords were chosen based on sources that:
- included research on the possible causes of feeding disorders in toddlers and preschool children,
- elucidated the influence of the family environment on the development of feeding disorders,
- demonstrated the role of parental nutrition education in the prevention of behavioral feeding disorders,
- discussed food familiarization strategies and dietary guidelines for parents.
CAUSES OF FEEDING DISORDERS
Feeding disorders in toddlers and preschool children can have behavioral or physiological underpinnings, or can be caused by a combination of these factors. Feeding disorders are presently classified into three main categories: decreased appetite, selective eating, and food phobia [8]. These categories are further divided into subcategories with organic and behavioral causes, and parental feeding styles are also taken into consideration. Parental dietary practices and feeding techniques also play an important role. For most parents, selective eating, food neophobia, food fussiness, food aversion, food avoidance, and restrictive food intake usually mean one thing – “my child refuses to eat”. However, these disorders imply more than just low food intake. These terms are not synonymous and can denote problems with a varied etiology. Feeding difficulties should be correctly interpreted by both children and parents to prevent eating disorders in later life [9].
SOCIAL AND ENVIRONMENTAL FACTORS INFLUENCING FEEDING DISORDERS
Food consumption is influenced by a wide range of factors which should be identified to address feeding difficulties in early life and minimize the risk of negative health outcomes [10]. Feeding disorders in children are a complex problem, which is why warning signs or behavioral red flags should not be disregarded [11]. Attention should also be paid to situations in which normal eating behaviors are perceived as feeding disorders. The above can lead to dysfunctional feeding practices, which is why all parents’ concerns should be adequately addressed [7].
Social and environmental factors, including dietary patterns and strategies introduced by parents, peer modeling, and emotions that accompany eating, also play a key role. These factors significantly influence a child’s eating behaviors and food choices. Dietary expansion also significantly contributes to a child’s optimal development. The introduction of new foods teaches children to make food choices and accept products with a varied texture, and it also plays a key role in the process of socialization [12].
Caregivers’ feeding style considerably affects the overall quality of children’s diets. Four feeding styles have been identified: authoritative, authoritarian, indulgent, and uninvolved. The authoritative style is associated with high responsiveness, where the caregiver focuses on the child, support’s the child’s autonomy, but also adapts to the child’s needs. The authoritative style contributes to the highest dietary quality in children, compared with the other styles, by promoting the child’s development of preferences for healthy foods and learning to correctly read the signs of hunger and satiety [13]. Feeding style is also influenced by the family’s financial status. The authoritative style is most prevalent in higher-income households, whereas the authoritarian style is more commonly observed in lower-income families [14]. The authoritarian style is a controlling style; it promotes the child’s autonomy only to a small extent and is based on strict adherence to the rules set by the parents. Thus, authoritarian feeding is characterized by attempts to control the child’s eating with little regard for the child’s choices and preferences. In shaping proper eating practices, boundaries are good if they relate to the type of food consumed, whereas authoritarian parenting can have a negative impact on children, including the development of emotional and behavioral problems related to eating [15]. The permissive style is characterized by low parents’ expectations towards the child and at the same time high responsiveness. Parents do not have many expectations regarding the quality and quantity of food consumed by their child. However, they are sensitive to the signals of hunger and satiety sent by the baby, and they also approach the issue of feeding emotionally. In turn, the uninvolved style combines both low requirements for the child’s nutrition and low responsiveness. Thus, parents are not involved in the child’s nutrition and do not pay attention to the child’s needs and signals.
Parents who use responsive feeding introduce meals in a predictable manner and pay attention to the child’s emotional, psychological and physiological needs to promote self-regulation. The meal schedule is planned in advance. Responsive feeding has been found to reduce food selectivity in children aged 2 to 5 years [16]. Optimally, RF involves the provision of nutrient-dense foods to support high diet quality, structured and predictable eating times, and a pleasant eating environment with family interactions and minimal distractions. Self-regulation is an essential developmental milestone. This ability is associated with fetal brain development as well as early childhood experiences, and it is a complex and multi-stage process. Self-regulation develops most rapidly between early pregnancy and the second year of life. This period marks the development of neurobehavioral functions, including anxiety regulation. The ability to identify and correctly respond to environmental threats is key to survival [17].
Self-regulation is also important in the context of dietary energy and sensitivity to hunger and satiety cues in infants. Breastfed babies are more satiety-responsive than bottle-fed infants [18]. Infants are dependent on their caregivers, mostly parents, who are responsible for attending to the child’s physical and emotional needs. Therefore, feeding strategies based on hunger and satiety cues encourage autonomy in eating, whereas controlling feeding practices can disrupt self-regulation. For example, parents who use food to soothe an infant that is stressed, but not hungry, may impair the development of appetite self-regulation, which can lead to emotional eating and eating disorders [19]. As practice shows, parents feel responsible for ensuring that their children have what they consider to be a healthy and varied diet. They believe that their role as caregivers is reflected in their ability to feed their children, and when expectations fail, eating anxiety can increase [20]. Mealtimes become stressful and negative experiences where parents are unable to enjoy the bond with their child, putting pressure on the child to eat. Consequently, it is difficult to determine whether these problems in parent-child interactions are the result or cause of eating disorders [20].
In children, feeding difficulties can result from sensory processing disorders. Sensory input is first organized by the lower brain and then processed in higher levels of the brain. Human sensory systems (auditory, visual, tactile, proprioceptive, and vestibular) have to function properly to receive and organize information, which promotes the development of more complex skills and abilities. The generation of precise and correct neuronal connections not only is essential for supporting basic cortical functions but also plays a key role in the prevention of neurodevelopmental disorders. A child with a sensory integration dysfunction will not be able to process various sensory stimuli, which can disrupt daily life activities and lead to feeding disorders [21].
FOOD NEOPHOBIA
Between the ages of 1 and 3 years, children not only learn to walk, talk and eat independently, but they also strive for autonomy by learning to regulate their emotions. It is believed that the first two years of life open a “window of opportunity” for shaping a child’s food and taste preferences. Changes in eating behaviors and reduced food intake may be associated with a child’s growing need for autonomy. Food neophobia usually develops between the ages of 2 and 6 years, when taste and flavor preferences evolve, and eating habits are shaped. During this period, many children refuse to try new foods, which is a natural stage in their development. Parents should assist their children in developing healthy dietary patterns, becoming familiar with new foods, and learning through observation and association. Pressure to eat usually has the opposite effect, and it further reduces a child’s food intake. Neophobic behaviors can be harmful to health, which is why they should not be disregarded [9, 22].
Food neophobia is linked with many factors, including individual predispositions, personality traits, age, gender, as well as biological, psychological, anthropological, economic, and cultural factors. Young children learn by observation, and any changes in the arrangement of food on a plate can have negative consequences.
Children may be unwilling to try foods that are perceived as new and unfamiliar [23]. Food neophobia is also associated with chemosensory responsiveness that varies across individuals. According to research, children with food neophobia tend to be more responsive to taste and perceive “warning” chemosensory sensations as more intense [24]. The above applies particularly to sour, bitter, astringent, and spicy foods. Neophobics tend to reject various foods, mostly vegetables, plant-based foods, and healthy low-processed foods [23, 25]. These children also have limited food texture preferences.
Children’s rejection of food containing particles was associated with a higher risk of food neophobia. Parental feeding practices and food preferences also affect children’s acceptance of food texture and consistency [26]. In comparison with adults, children are more sensitive not only to the consistency of food but also to its color. Food intake can be influenced by color, which could explain why children have a preference for orange vegetables, which are sweeter than green vegetables. In general, children have a heightened preference for the sweet taste, which could guide their food choices [27]. Food neophobia is also frequently associated with emotional disorders such as anxiety, which is a genetically conditioned trait. Numerous gene variants have been linked with anxiety, and they can play a decisive role in many diseases and disorders. However, parental pressure to eat can exacerbate anxiety. Food neophobia may develop when a child is forced to eat, when parents do not respect the child’s food preferences, and do not involve the child in meal preparation [28].
POTENTIAL HEALTH CONSEQUENCES
Pediatric feeding disorders increase the risk of nutrient deficiencies. Children who are selective eaters are more susceptible to diseases caused by vitamin and mineral deficiencies. Diets deficient in calories and protein can lead to weight loss, malnutrition, stunted growth and frequent infections, which can compromise cognitive development, memory, emotional regulation, and behavior in children. Pediatric feeding difficulties can also contribute to eating disorders in adolescence and adulthood [29].
Food neophobia is one of the reasons why children limit their intake of fruits and vegetables. Adequate consumption of these products is critical for health. A report published by the World Health Organization stated that, if consumed in the recommended amounts, fruits and vegetables reduce the risk of noncommunicable diseases, including coronary heart disease, stroke, and some types of cancers [30]. Children who enjoy processed foods are at greater risk of non-infectious diseases in adulthood [31].
This diet is a poor source of essential nutrients, and it can contribute to health problems and developmental issues in children [32]. Food neophobia has also been linked with a higher body mass index (BMI). This may particularly apply to selective eaters who limit their intake of vegetables, fruits, nuts, and legumes and have a preference for highly processed foods, including fast foods and sweets [33]. In addition, pressure to eat and force-feeding exacerbate neophobic behaviors, prevent children from forming social relationships, and negatively impact a child’s daily functioning in a peer group. Some studies have shown that the daily life and social participation of children and their families are negatively impacted by feeding disorders [34]. Quality of life impacts are also likely exacerbated by the lack of support for families, lack of evidence-based care guidelines, and lack of trained professionals [34].
STRATEGIES AND RECOMMENDATIONS
Pediatric feeding disorders are evaluated based on a thorough analysis of the child’s medical history, an interview with the child’s primary caregivers, a clinical examination, and observations of feeding and eating behavior at mealtime. Such assessments are essential for designing coping strategies that are tailored to the child’s and the family’s needs [5]. Observational analyses can be conducted based on video recordings of a child’s mealtime behavior. This approach makes it possible to perform a reliable assessment in the home environment [34].
Nutritional guidelines specify parental feeding styles and practices that can reduce the risk of pediatric feeding disorders. Parents should avoid mealtime distractions, control the child’s posture during a meal, and limit meal duration. Children should receive 4-6 meals/snacks per day with water in between, and the served foods should be age-appropriate. Parents should also tolerate age-appropriate mess during meals, encourage self-feeding, and systematically offer new foods [6]. Effective feeding practices will enable a child to achieve developmental milestones and will contribute to its health and wellbeing in the future. Whenever possible, children should be exclusively breastfed in the first six months of life, and age-appropriate complementary feeding and new foods should be introduced before the age of two years. The age at which infants start receiving complementary foods significantly contributes to healthy eating habits and behaviors. Complementary feeding practices should not begin too early or too late [35]. Baby-led weaning (BLW) facilitates complementary feeding, and it can decrease the risk of feeding disorders in later life [36]. In this approach, children are offered solid foods to feed themselves. In babies that eat mostly independently, occasional spoon-feeding is not a problem, but excessive spoon-feeding by parents increases the risk of feeding difficulties [37]. For children, the opportunity to eat by themselves has many benefits, not only nutritional. The opportunity for the child to eat on his or her own strengthens his or her development and draws his or her attention to the variety of foods offered rather than the person serving the food. Children who have the opportunity to eat freely not only improve their feeding skills in the nutritional sense but also develop the precision of grasping the products, and motor coordination, become active participants in the meal, and are involved in the full process, in contrast to infants who do not have the opportunity to reach for food independently and become an inactive child during the feeding process [36]. Parental views on child feeding and their willingness to implement experiential learning strategies (through sensory play and games) also play an important role in shaping desirable feeding behaviors and increasing the child’s intake of fruits and vegetables. Parents who feel helpless and are not confident that a given feeding strategy would work for their child are unlikely to succeed. Parents should be engaged, confident, and should select feeding strategies that are most likely to deliver positive outcomes in their children [38, 39]. Parental feeding strategies such as force-feeding or restricting food access are ineffective and counterproductive. Children are quick to make associations between foods and unpleasant experiences that accompany them. If a child is pressured to eat, negative emotional feelings can become associated with a particular food item, leading to a decrease in food liking [40] and reduced acceptance and intake of vegetables [40]. A reward and punishment system is equally ineffective in the long term and should be avoided [41]. Offering rewards for eating or bargaining with picky eaters may deliver benefits, but only if the child is willing to try a novel product on the spot. However, children tend to categorize foods, and fussy eaters are likely to reject fruits and vegetables before even trying them, and refuse to eat. Fruits and vegetables are the most disliked food category, which is why modeling interventions based on experience appear to be most effective.
Food play that engages numerous senses is an effective approach to familiarizing children with foods. At the beginning, not all food games have to focus on taste or novel foods. Food play can involve various food products as well as toys. Visual exposure to foods in picture books and picture-based games is also recommended. Funny stories involving cartoon characters, coloring books, food play engaging various senses (not necessarily taste) and role-playing relating to cooking and shopping for food can also come in useful [42]. Children who are not pressured to eat are more willing to try novel foods when they participate in food play [42, 43]. Parents can effectively familiarize children with foods by engaging them in planning meals, shopping for food, cooking, and eating family meals [44]. Parents should actively involve children in cooking, meal preparation, and food shopping to prevent food disorders and reduce their severity. Children who are engaged in these activities come into direct contact with fruits and vegetables, and are more likely to accept novel foods, including vegetables. Children also expand their knowledge about the shape, color, aroma, and consistency of various foods. Learning cooking skills contributes to a sense of self-efficacy and boosts confidence (“I cooked it myself” effect). Research has shown that people like or even overvalue objects they have created themselves. Those who cook perceive self-prepared meals as tastier and more natural, and they are less likely to buy highly processed foods [44-46]. However, older children are more susceptible to peer influence, and greater effort, including education, is required to instill healthy eating habits and change unhealthy ones [47, 48].
The home environment, in particular the accessibility of food, plays an important role in shaping eating habits. Parents can restrict access to unhealthy foods (such as potato chips, cookies, and candy) by storing them out of the children’s reach without the need for overt restriction and excessive rules and limits. To encourage the consumption of healthy foods, parents can keep them in the open (for example, in a fruit bowl) and in ready-to-eat form (washed and cut). Children learn through observation, and parents should participate in meal preparation, preferably from the beginning to the end of the process. Healthy food preparation methods always deliver health benefits for children. Sensory-based food education also generates positive outcomes by increasing children’s intake of fruits and vegetables, and this approach should be used to prevent selective eating [49].
Children follow their caregivers’ eating behaviors and attitudes towards food, which is why nutrition education programs should be addressed primarily to parents. These programs should encourage parents to support a child’s autonomy. The messages used by parents should be adjusted to match the child’s developmental stage. Parents of young children should use simple messages about which foods are healthy and help children grow. These messages can become more complex as children grow older [14]. Meals should be predictable, and the child’s emotional, psychological, and physiological needs should be adequately addressed. A child should also learn to rely on hunger and satiety clues to self-regulate its food intake [16].
An important element in the prevention of feeding disorders is maternal nutrition before and during pregnancy. It can significantly affect fetal development (“fetal programming”) and the child’s health and wellbeing in subsequent stages of life [50], which is why prospective mothers should modify their dietary habits accordingly both before and during pregnancy. A healthy diet should be continued postpartum not only to improve the mother’s health but also to set a good example for children, who learn through experience and observation. Food familiarization is essential for food acceptance, and feeding strategies should target as many senses as possible.
The main limitation of this narrative review is the focus on behavioral feeding disorders only, without considering those that may be related to the presence of medically based illnesses or accompanying disability. The paper does not analyze the health consequences of poor feeding or the occurrence of nutritional deficiencies, and it primarily focuses on discussing strategies for managing eating problems and education provided by a dietician or a feeding therapist. A compilation of information on the influence of the family environment on the development of feeding disorders, as well as different feeding methods and styles, can be a good source of knowledge for both those dealing with and those affected by the discussed problems.
Another limitation is the fact that the adopted literature review parameters excluded books, book chapters, conference proceedings, and articles that have not yet been published or have been published in languages other than English. As a result, some relevant sources may have been overlooked. Furthermore, restricting the database search to PubMed, Scopus, and Web of Science might have limited the number of studies included in the review.
CONCLUSIONS
Pediatric feeding disorders have a complex etiology, and they are diagnosed based on detailed nutritional assessments, interviews with the child’s primary caregivers and survey questionnaires, and observations of feeding and eating behavior at mealtime. Physiological factors should be ruled out, and an action plan that is tailored to the child’s individual needs should be developed. Depending on their type and severity, feeding disorders can be addressed in the home environment or may require an interdisciplinary approach involving physicians, psychologists, dieticians, and sensory integration therapists (Diagram 1).
Prevention and nutrition education play a very important role in shaping positive eating habits, minimizing the risk of pediatric feeding difficulties. The problem of feeding disorders in children should not be underestimated, because appropriate actions taken at an early stage make it possible to solve the existing problem and prevent future consequences, thereby improving the quality of life of the child and the family.
DISCLOSURE
The authors report no conflict of interest.
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