Fussy eating is reported by up to half the parents of children aged one to 10 years old in Singapore. Eating is a complex task that can be challenging for young children and their parents. While most children outgrow fussy eating behaviours by school-going age, prolonged fussy eating can negatively impact their nutritional intake, growth and development.

What are some common reasons for fussy eating in children?

Fussy eating in children includes behaviours such as eating slowly, refusing fruits and vegetables, preferring sweet and fatty foods, and unwillingness to try new foods1. Common reasons for fussy eating are:
  • Delayed introduction of lumpy foods – Reports have found that the late introduction of lumpy foods after nine months of age result in a higher likelihood of fussy eating behaviours at preschool age2.
  • New and unfamiliar foods – A typically developing child may reject new and unfamiliar foods from the first year of life. This behaviour peaks between the ages of 18 and 36 months. At this developmental stage, children start to express their autonomy and attempt to exert control over their environment2,3.
  • Maladaptive feeding practices – When children do not meet expectations about what and how much they should eat, parental worry can lead to less-than-ideal feeding practices such as force feeding, and using distractions, punishment or bribery. These can cause resistance in the child, worsen pre-existing negative associations with food, and further perpetuate fussy eating behaviours4,5.

How can parents cultivate healthy eating habits?

Learning good eating skills and habits from infancy is critical for child growth and development, and sets the foundation for a healthy relationship with food and eating into adolescence and adulthood.

​Advice for healthy eating habits in children

0 to 12 months old
  • Respond to your child’s feeding cues
Focus on responsive feeding from infancy. Watch for your child’s hunger cues such as placing their hands in the mouth, smacking lips, turning when their cheek is touched (rooting), and respond by offering a feed. Stop feeding when your child shows signs of being full. This helps your child to develop clear hunger-satiation cues, and helps parents to learn to respect and respond to the cues.6

  • Give your child food textures and variety appropriate for their age
Introduce a variety of solid food textures from six months of age. Gradually provide foods from all food groups (i.e. starches, proteins, fruits and vegetables), which match your child’s developmental age. This helps your child to develop feeding skills (e.g. chewing, self-feeding with fingers or utensils) and to accept different textures and flavours.


  • Set consistent mealtime routines and structures
Establish routines and structures such as eating at fixed timings, sitting at the table, avoiding screen time or toys as distractions, and having meals together to facilitate positive social experiences around food.


12 months and above
  • Engage in family mealtimes and introduce adult foods to your child
Children learn best from watching others eat. Have family mealtimes together and gradually introduce adult foods. Help your child during the meal (e.g. cut up adult foods to smaller pieces and provide a spoon with pre-scooped food to facilitate self-feeding).

  • Involve the whole family in preparing for a meal
Help your child to form positive experiences during mealtimes by involving them in meal preparation activities such as washing vegetables or setting the table.

  • Model good feeding practices and keep mealtimes positive
Model good feeding practices such as eating a balanced diet, trying unfamiliar foods and putting away the phone during mealtimes. Allow your child to self-feed and present food in visually appealing ways (e.g. different colours or shapes, using attractive utensils). Have a conversation around your child’s day instead of over-focusing on food.

  • Limit snacks
Promote appetite by limiting access to snacks, high-energy foods and milk two hours before mealtime3, to help your child recognise their own hunger satiation cues. Children may eat more and be more willing to try new foods when they feel hungry.

  • Be realistic about your child’s eating portion
Set realistic expectations of a child’s portion size3. For a children aged one to two years, usual portions are a fifth to a quarter of an adult meal; for children aged three to six years, this would be a third to half of an adult portion. Similar to adults, there can be variability in your child’s appetite, food preferences and intake from day to day – they may eat well on certain days and at other times, eat less. It is acceptable should your child still grow well, and eat a variety of starches, proteins, fruits and vegetables.

  • Offer a variety of foods at every mealtime
Continue to offer your child a variety of foods, both preferred and non-preferred, at every mealtime. As your child’s sense of autonomy grows, involve them in making deciding some meal aspects such as the type of spread on a sandwich.


When should parents seek medical advice?

It can be challenging to identify specific causes of fussy eating, as these can be complex, multi-factorial and inter-dependent. Parents are recommended to seek medical advice from community healthcare professionals if their child exhibits persistent fussy eating concerns daily for two weeks or more7.

Community healthcare professionals can assess and refer children with persistent fussy eating behaviours to paediatricians, to rule out any medical issues, such as gastrointestinal reflux or allergies. Should there be minimal improvement following general child eating advice, referrals to other healthcare professionals such as dietitians and therapists may be needed to address concerns in nutrition, feeding skills and psychosocial domains.7

​Domains of concern related to fussy eating
Nutrition and diet

Children with fussy eating behaviours may have a restrictive diet (less than 20 types of foods).

The child may:
  • Be at risk of medical problems including nutrient deficiencies, gastrointestinal problems such as constipation, and faltering growth.
  • Be under- or overweight for their age, due to refusing or over-consuming certain foods.
What can be done?
  • Dietitians can assess a child’s nutritional adequacy and suggest strategies to meet growth and nutrient needs through food and/or supplementation.
Feeding skills

Persistent fussy feeding behaviours can be due to underlying deficits in age-appropriate and efficient feeding skills. Delays in motor skills, language, socialisation and cognition can also adversely impact on the development of feeding skills.

The child may:
  • Be unaware or overly aware of foods or liquids in the mouth, leading to gagging or vomiting, or resulting in specific food preferences.
  • Have difficulty chewing, or when using eating utensils.
What can be done?
  • Paediatricians can assess and address any delays in motor skills, language, socialisation and cognition which may impact the development of feeding skills.
  • Speech and occupational therapists can support the development of feeding skills using oro-motor therapy and sensory-based approaches.
​Psychosocial

Parenting influences a child’s eating habits and vice versa5. Strategies such as only offering preferred foods, force feeding or bottle-feeding beyond the recommended age can form a vicious cycle of children developing a strong dislike for food, and caregivers continuing to engage in less-than-ideal feeding practices.

Families may:
  • Experience significant stress around feeding
  • Have difficulties managing the child’s feeding behaviours
  • Have difficulties introducing new foods or appropriate diet variety
What can be done?
  • Professional support can help parents to learn responsive feeding practices to enable their children to develop healthy food preferences and a well-regulated appetite, and improve the quality of parent-child interaction at mealtimes.

​Refer a patient

KK Women’s and Children’s Hospital (KKH) provides holistic assessment, intervention and support for child nutrition, feeding skills and psychosocial concerns related to feeding6.

Healthcare professionals can contact the KKH Central Appointments Hotline +65 6294 4050 to refer a child for assessment by the General Paediatrics Service.

​Resources

Useful information on children’s diet:
Feeding tips and strategies:


​
 ​Dr Ong Chengsi, Principal Dietitian, Nutrition and Dietetics Department, KKH

Dr Ong Chengsi specialises in the nutritional management of critically ill children and very low birth weight infants at KKH. She is a Registered Dietitian in the United States of America (USA) and a Certified Nutrition Support Clinician. Her research interests include the roles between nutrition, growth and body composition.
​
 ​Stacy Tan, Principal Speech Therapist, Speech Language Therapy Service, KKH

Ms Stacy Tan specialises in the management of infants and children with complex feeding and swallowing disorders at KKH. She graduated from La Trobe University in Australia with a Bachelor in Speech Language Pathology (Honours).
​
 ​Jo Chen, Senior Principal Occupational Therapist, Occupational Therapy Service, KKH

Ms Jo Chen specialises in the management of children with fussy eating at KKH, and has been working in the paediatric field for over 15 years. She also works closely with children with complex needs and their families.


​References
  1. Goh, D.Y.T, & Jacob, A. (2012). Perception of picky eating among children in Singapore and its impact on caregivers: a questionnaire survey. Asia Pacific Family Medicine, 11:5. http://doi.org/10.1186/1447-056X-11-5
  2. Taylor, C.M., & Emmett, P.M. (2019). Picky eating in children: Causes and consequences. Proceedings of the Nutrition Society, 78(2), 161-169. http://doi.org/10.1017/S0029665118002586
  3. Białek-Dratwa, A., Szczepa´nska, E., Szyma´nska, D., Grajek, M., Krupa-Kotara, K., & Kowalski, O. (2022). Neophobia - A natural developmental stage or feeding difficulties for children? Nutrients, 14, 1521. https://doi.org/10.3390/nu14071521
  4. Jansen, P.W., de Barse, L.M., Jaddoe, V.W.V, Verhulst, F.C., Franco, O.H., & Tiemeier, H. (2017). Bi-directional association between fussy eating and parents’ pressure to eat: Who influencies whom. Physiology & Behavior, 176, 101-106. http://doi.org/10.1016/j.physbeh.2017.02.015
  5. Walton, K., Kuczynski, L., Haycraft, E., Breen, A., & Haines, J. (2017). Time to re-think picky eating?: A relational approach to understanding picky eating. International Journal of Behavioral Nutrition and Physical Activity 14:62. http://doi.org/10.1186/s12966-017-0520-0
  6. Pérez-Escamilla, R., Jimenez, E.Y., Dewey, K.G. (2021). Responsive feeding recommendations: Harmonizing integration into dietary guidelines for infants and young children. Current Developments in Nutrition, 5(6), nzab076. https://doi.org/10.1093/cdn/nzab076
  7. Goday P.S., Huh S.Y., Silverman A., et al. (2019). Pediatric feeding disorder: Consensus definition and conceptual framework. J Pediatr Gastroenterol Nutr; 68(1):124-129. https://doi:10.1097/MPG.0000000000002188