Picky Eating: A Toddler's Approach to Mealtime

Mary Cathey; Nan Gaylord

Posted 05/10/2004

Abstract and Introduction

Abstract

Research indicates that three primary components play a role in the picky eating phenomenon: development, personal preferences, and the family. Picky eating is an aspect of child development. Children will develop their own preferences when given the appropriate tools to do so. Parents are their children's greatest role models. An understanding of these concepts can help guide the primary care provider in making appropriate recommendations to parents to improve their toddlers' eating behaviors.

Introduction

The toddler years represent a challenging time characterized by rapid development that can be exciting, as well as frustrating. Though the toddler is beginning to establish his or her independence, he or she is still reliant upon a caregiver to provide for all basic needs. This may present a bit of a problem if the toddler's desires differ from those of the caregiver. This behavior is perhaps most evident in the development of eating behaviors in young children. In the interest of offering their children the best start possible, parents of toddlers will come to their primary care providers searching for answers and recommendations to a myriad of concerns regarding dietary intake. Many parents are well aware of the need to establish healthy dietary habits early in life, as well as, the link between poor nutrition and adverse health conditions (Fisher & Birch, 1995). Concerns peak when the child demonstrates an unwillingness to try novel or unfamiliar foods, termed food neophobia (Carruth & Skinner, 2000). We, as primary care providers, must be prepared to offer sound advice and solid recommendations to these parents as they struggle to provide their children with the tools necessary to become healthy, happy adults.

The Picky Eating Phenomenon

Three primary components play a role in the picky eating phenomenon. These components are development, personal preferences, and the family.

The Role of Development

To develop appropriate recommendations, it is necessary to gain an understanding of the determinants of dietary patterns in young children. The literature provides support for the idea that picky eating is a developmental process for toddlers. Johnson (2002) described food acceptance patterns and the emergence of eating patterns in relation to physiologic growth, age, and emotional development. In infancy, a child is a depletion-driven eater who consumes only milk and has no desire for other foods. As the child grows, he or she develops a physiologic need for more nutrients and is, therefore, transitioned to solid foods. This is followed by the stage of food neophobia and the "terrible twos," when the child attempts to assert his or her independence and to establish some sense of autonomy. Johnson (2002) sees this as a normal part of development that leads to frustration, anxiety, and power struggles between the parent and child. Eventually, the child develops cognitively in the preschool years to begin to understand physiologic and social cues needed to respond appropriately to adults and will not engage in these power struggles as readily (Johnson, 2002). This clearly represents a stage of development that resolves as the child matures.

Martins (2002) describes toddlers' neophobia as a developmental phase that is rooted in a historical practice, which has remained ingrained despite the evolution of our culture. She purports that this may be an innate phase that may have served a protective function during the time when humans foraged for food. A fear of unfamiliar foods decreased the likelihood of inadvertently eating a harmful toxin at a time when this was a significant threat. Even though this is no longer an ominous threat to survival, toddlers are innately programmed to be a bit skeptical of unfamiliar food items and, thus, demonstrate picky eating habits for a period of time (Martins, 2002).

Picky eating, though it may appear to be dangerous to the child's well being, will not, in most cases, be a detriment to the child's health. Birch and Fisher (1995) report that almost all children will self-regulate the ingestion of the appropriate amount of nutrients needed to sustain growth and further development. In other words, the toddler will eat what is needed to support his or her growth. Satter's (1990) work indicating that a child will assume responsibility for whether or not he or she will eat and what amount will be ingested further supports this notion. This innate or automatic mechanism demonstrates that the child's picky eating behavior is to some degree internally mediated, which implies that there is a developmental component.

The Role of Personal Preferences

In addition to the belief that picky eating is a developmental phase, research provides support for the fact that children demonstrate personal preferences, which will help determine the food choices they make. By reviewing the psychologic influences on dietary intake of children found within the literature and tying them in with her own ideas, Birch (1998) concluded that few food preferences are innate. Rather, they are found through trial and error of the child. When these preferences are determined, young children simply eat what they like with no regard to fat, cholesterol, or sodium content. She purports that these preferences, when considered in the context of family values, attitudes, and beliefs and with respect to emotional states, help determine future dietary and intake patterns (Birch, 1998).

Fisher and Birch (1995) provide further evidence on the importance of food preferences in the development of eating behaviors. The authors studied children aged 3 to 5 years old to determine the importance of food preferences in the development of dietary intake patterns. The researchers observed each participant's 24-hour food intake from prepared choices that consisted of healthy and unhealthy food options. Each child's actual intake was compared with the results of the Fat Preference Assessment obtained earlier in the study. The authors hypothesized that children with a strong preference for high fat foods were more likely to eat foods high in fat. This proved to be true as the measured fat intake ranged from 25% to 42% of total consumed energy. The higher percentages were observed in those children demonstrating a greater preference for high fat foods (Fisher & Birch, 1995). Understanding the role of preferences in dietary choices of toddlers is critical to identifying appropriate interventions to address neophobic food behaviors.

In examining the importance of personal preferences in toddlers' food choices, a brief discussion regarding the impact of exposure to novel flavors via mother's milk in breastfed infants is critical. Mennella, Jagnow, and Beauchamp (2001) hypothesized that exposure to a particular flavor in breast milk or amniotic fluid would modify an infant's response to and acceptance of that flavor when transitioned to solid foods. In a study of 46 mothers and their infants, the authors offered one group of pregnant women carrot juice 4 times per week during the last trimester of pregnancy and water during the first 2 months of lactation. The second group was given water during the pregnancy and carrot juice during lactation, while the third was offered water throughout both pregnancy and lactation. At about 6 months of age, the infants' diets were complemented with cereal. Approximately 4 weeks later, the flavor of carrot was added to assess responses. Each mother rated her child's enjoyment of the new food item according to a 9-point scale with 9 indicating the food was liked very much and 1 implying that the food was not liked at all. The researchers analyzed each infant's response based on facial expressions and negative responses including gaping, head turning, brow lowering, and nose wrinkling. These authors found that the infants exposed to the carrot flavor prenatally or in breast milk exhibited fewer negative responses and facial expressions when presented with it when weaning to solid foods, thus supporting their hypothesis (Mennella et al., 2001). This significant finding lends support to the idea that food exposures may play a pivotal role in acceptance of novel foods and unfamiliar flavors.

An earlier study examined the outcomes of garlic ingestion by nursing mothers on the odor of their breast milk and the subsequent suckling behaviors demonstrated by their infants. Mennella & Beauchamp (1991) found a significant increase in the odor of the mother's milk approximately 1 hour after ingestion, during which time each infant tended to nurse longer and suck more. These early breastfeeding experiences may play a significant role in the development of food preferences.

The Role of the Family

Much of the research regarding the development of eating patterns and picky eating in young children addresses the influence of the family, particularly that of the parents. The concept of the parent as a role model cannot be overlooked in a comprehensive discussion of the roots of the picky eating phenomenon. A quantitative meta-analysis looking at early research findings found that food preferences of parents were positively correlated to children's food preferences. The analysis at that time included only five published studies meeting the criteria of specifically addressing food preferences and comparing the preferences of each parent/child pair. The authors of this analysis concluded that further studies investigating the correlation of food preferences of children with related and unrelated adults should be conducted to further our knowledge of the development of dietary habits and food consumption (Borah-Giddens & Falciglia, 1993).

Since then, several studies have been published to support the notion that parents exert a great deal of influence on the development of dietary habits in their children. A quantitative study published in 1998 examined whether food preferences of toddlers were in concordance with the food preferences of their family members (Skinner et al., 1998). The researchers administered a questionnaire regarding personal food preferences to each parent and to each older sibling of 118 children aged 28 to 36 months. In addition, the primary caregiver completed the same questionnaire for the toddler in the study. Statistical analysis determined a high concordance for liked foods between the toddler and other family members, while a low concordance was found for disliked foods. In addition, the most limiting factor related to toddler's food preferences were those choices never offered by the parents (Skinner et al., 1998).

A slightly larger longitudinal study of 351 Mexican-American and non-Hispanic White children in the San Diego area set out to determine the influences of intake patterns by comprehensively examining 35 variables including those of the social/parental domain (Zive et al., 1998). Statistical analysis revealed that parents who avoided fat and salt in their diets were found to have children who consumed less total energy in the form of calories. The researchers also concluded that strict parental control over dietary intake may inhibit the child's ability to learn self-control, thus leading to overeating and obesity (Zive et al., 1998).

Messina, Weidner, and Connor (2002) hypothesized that parental attitudes toward nutrition and parental dietary habits influence their children's choices. They believed that parents' poor attitudes and habits could result in adverse health outcomes for their children. In a study of (AU: HOW MANY?) mothers and their daughters, the authors found that a relationship existed between mothers' attitudes toward nutrition and daughters' cholesterol levels. The study suggests that it may be of great importance to plan intervention programs to improve parents' attitudes concerning health and nutrition in an effort to improve the health outcomes of their children (Messina et al., 2002). Obviously, parental influence is a critical factor in the establishment of children's dietary patterns.

Carruth and Skinner (2000) report that mothers who model food neophobia influence the neophobic behaviors of their children. A young child will probably be less willing to try a novel food that his or her mother has not tasted. Young children will be less accepting of unfamiliar food items if they observe their parents' picky eating behaviors. These types of maternal behaviors will continually influence the child's neophobic behaviors beyond the picky eating phenomenon of toddlerhood (Carruth & Skinner, 2000).

Recommendations for the Picky Eater

Recognizing that dietary behaviors and picky eating habits are a result of development, a child's food preferences, and parental role modeling is important. Bearing these points in mind, appropriate recommendations begin to evolve. The primary care provider's role is to lead this discussion with the frustrated parent in need of sound advice.

Overall, it seems to be most important to reiterate to frustrated parents that toddlers are no longer in a period of rapid growth as they were during the first year of life. Bright Futures in Practice: Nutrition (Story, Holt, Soffka, 2002) reports that children between the ages of 2 and 5 years old gain an average of 4.5 to 6.5 pounds annually. This is a huge growth decline when compared with the first 2 years of life during which time the child is expected to quadruple his or her birth weight. Toddler's nutritional requirements decrease, their appetites decline, and their feeding patterns may become unpredictable (Story et al., 2002). Parents must understand that it is unrealistic to expect a toddler to eat a large amount of food at each meal every day. After all, a toddler's stomach is approximately the same size as his or her clenched fist (Martins, 2002).

The literature supports the idea that picky toddlers require several exposures to novel food items before they will accept them, another important concept to reiterate to the parents of picky eaters. Birch and Marlin (1982) conducted an experiment examining this relationship between exposure to novel foods and acceptance by 2-year-old children. Their results indicated that an increase in exposure frequency helped determine child preferences, and therefore, influenced what the child agreed to eat. Most of these children required as many as 10 exposures to the novel food choice before they were willing to accept it. The authors cautioned that although their results were found to be quite statistically significant, food exposure is not the sole determinant of young children's food acceptance (Birch & Marlin, 1982).

Carruth and colleagues (1998) reported that young children need frequent exposures to new food items both at home and away from home to have the opportunity to learn about them. A child cannot learn to accept a new item without frequent exposure. They describe a lack of offering of specific foods to a young child as the most limiting factor in the development of food choices. In addition, a child may have a tendency to reject additional food items that have a similar visual appearance to that initial item to which he or she was not adequately exposed. These authors suggest that parents need ideas concerning age appropriate experiences needed to help the toddler learn to accept a wide array of foods and to ingest adequate amounts of needed energy and nutrients (Carruth et al., 1998).

Frustrated parents will often describe their toddlers' mealtimes as a battle of wills filled with annoyance, anger, and disappointment. Much of the literature addresses these power struggles that may ensue as the overwhelmed parent attempts to exert control on the young toddler who is willful and stubborn. Parents need to know that forcing a toddler to eat by punishment or threats may only serve to worsen the picky eating habits and the power struggles. Satter (1986) writes that children who are consistently punished or have food forced upon them will come to associate hunger and mealtime with anxiety and frustration, rather than pleasure. Over time, this frustration and anxiety will continue to escalate and worsen those picky eating habits.

The disruptive picky eating behaviors described by parents oftentimes result in unpleasant, anxiety-provoking mealtimes. In a study of 45 children, Sanders and colleagues (1993) clearly showed that parents of children with eating difficulties were more likely to use unsuccessful coercive techniques at mealtimes, which ultimately led to persistence of the child's feeding problems. As the parents used negative prompts, negative physical contact, and negative feeding comments, their children engaged in more disruptive behaviors throughout the meal. These children developed more patterns of food refusal, which escalated the use of coercive techniques by parents. Although the parents' intentions were positive and well meant, mealtimes tended to become virtual war zones as a result of the significant power struggles (Sanders, Patel, Le Grice, & Shepherd, 1993).

In addition to worsening the picky eating behaviors, an exorbitant amount of control over consumption patterns may lead to an inability to respond to self-regulation cues and an increase in distaste for certain foods. Birch and Fisher (1998) report that children who are highly encouraged or forced to consume foods may not be able to use internal signals of hunger and satiety as a means of adjusting energy intake as readily as other children. In addition, they found that strategies forcing a child to consume a particular food may actually increase the child's distaste for that food (Birch & Fisher, 1998).

Johnson and Birch (1994) likewise concluded in their study that there is indeed a link between child-feeding practices and the child's responsiveness to self-regulation cues. They reported that parents who wield a great degree of control over what and how much their children eat will tend to have children who demonstrate low self-control and an inability to self-regulate energy intake (Johnson & Birch, 1994).

Finally, Gottesman (2002) reminds us to reiterate to these frustrated parents that it is their job to determine what, where, and when their child is fed. It is the child's job to determine whether or not he or she will eat and what he or she will ingest. When the well-meaning parent bribes, punishes, demands, or forces the child to eat, he or she crosses the line into the area that the toddler controls. This practice results in the negative behaviors, power struggles, and temper tantrums that characterize mealtimes of picky eating toddlers (Gottesman, 2002). It is important to remember that obtaining a sense of autonomy and independence is a significant feat in a toddler's development and one that parents cannot challenge.

During the infancy stage, children are typically demand feeders, meaning they demonstrate hunger cues when they are ready to eat so the primary caregiver offers them a bottle or the breast and their demands are satisfied. Later, as a child reaches the toddler years, he or she becomes mature enough to accept a schedule and should be expected to follow a routine. This is an important concept for parents of picky eaters to understand. Gottesman (2002) reports that accommodating to the daily schedule of family mealtimes is an important aspect of development that allows the toddler to begin to fit into his or her enlarging social world. The child should be expected to sit with the family at designated mealtimes regardless of whether or not he or she chooses to eat. In addition, the child should be offered the same foods prepared for the entire family as a means of providing exposures in an attempt to diversify the diet.

In an article published in 1986, Satter addresses the issue of establishing a schedule or routine in the toddler who is engaging in aggressive and disruptive behaviors at mealtime. She explains that a toddler tests the limits parents imposed in every aspect of feeding including quantity consumed, preferences ingested, and tempo of food intake. It is the parent's responsibility to allow the developing child to express him or herself in an acceptable manner (Satter, 1986). That is, the child may choose to not consume particular foods offered at mealtime, but he or she is expected to remain at the table during the designated time. The toddler can choose to merely push around and play with the food on his or her plate, but he or she is not allowed to leave the table to play a different game. This is a difficult recommendation to make frustrated parents understand. However, allowing the toddlers' desires to override the limits imposed by parents will result in an exacerbation of negative feeding behaviors and an escalation of picky eating.

Occasionally, parents of children who possess these neophobic behaviors will admit to succumbing to the desires of their toddlers. Tired and frustrated parents may report that they serve their child precisely what he or she demands in an effort to get the child to ingest some nutrients, even if it is not the ones the parent desired. Satter (2002) cautions parents about this practice and about becoming what she terms "the child's short order cook." A child will always take the familiar, easy way out at mealtime if the parent continually fixes the child's entrees of choice. She recommends that a toddler be continually served healthy food choices as part of the family meal until these choices become the familiar and preferred items (Satter, 2002). This concept is important for tired and frustrated parents to understand. Although short order cooking is a quick fix to the power struggles in the present, it may further ingrain food neophobic behaviors that will only become more and more challenging and difficult to change as time goes on.

Oftentimes, well meaning parents of children who are picky eaters will mistakenly offer their children unlimited amounts of fruit juices or milk as a means of providing needed nutrients. Parents have been incorrectly led to believe that juices are a very nutritious addition to their child's diet. When children are allowed to fill up on these items, their appetites for other foods will suffer significantly (Gottesman, 2002). The American Academy of Pediatrics (AAP) (2001) has warned that juices contain excessive amounts of sugar, little or no calcium, no fiber, minute amounts of fluoride, and a high concentration of carbohydrates. Overconsumption of these juices can contribute to undernutrition, diarrhea, and the development of dental caries. The Academy's Committee on Nutrition recommends that children aged 1 to 6 years old be allowed to drink only 4 to 6 ounces of juice per day (AAP, 2001). In addition, experts recommend that toddlers drink 16 to 24 ounces of whole milk daily (Gottesman, 2002). This amount is enough to promote growth, but not so much that it decreases their appetites for other foods.

In addition to limiting the intake of juices and milk, parents need to be reminded of the importance of portion control in managing mealtimes and snack times with their picky eaters. As mentioned earlier, a toddler's stomach is about the size of his or her clenched fist (Martins, 2002). Obviously, youngsters are unable to eat anywhere near the amount of food that adolescents and adults ingest. Also, toddlers are trying to gain a sense of control over their environment. When toddlers are able to clean their plate and ask for more, they have successfully controlled one aspect of the mealtime and have made their own decision to invite the parent to serve them more. These points magnify the value of offering appropriate portion sizes to these young children. Story and colleagues' Bright Futures in Practice: Nutrition (2002) provides a modified food guide for young children. It recommends that children aged 2 to 6 years old eat 5 servings of grains daily, 3 servings of vegetables, 2 servings of fruits, 2 servings of dairy, 2 servings of meat, and sparse amounts of sweets and fats. In addition, it provides a chart of serving sizes appropriate for children in this age group. For instance, a half of a slice of bread, 2 cups of cooked vegetables or canned fruits, 2/3 of a cup of yogurt, and 2 tablespoons of ground meat represent adequate serving sizes from each of the respective groups on the food guide pyramid (Story et al., 2002). Such information is necessary for parents to plan mealtimes and snack times accordingly for their toddlers. In addition, primary care providers can easily access this information and offer it to frustrated parents in the form of an educational handout.

Through discussions with the parents of picky eaters, the primary care provider can begin to gather an idea of what the individualized mealtime in each family entails. This may include the structure of the meal, the presence of distracters such as the television during the meal, and the participants of the meal. Each of these aspects may play a considerable role in a toddler's actions and behaviors during the course of the meal.

Over the past few decades, a wide array of studies concerning the extent to which distracters such as television influence dietary patterns have been conducted. While much of the research has looked at behavioral links between television and children's food consumption patterns, as well as, the content of nutritional messages seen by children, very few have examined the associations between children's overall food consumption and television viewing. Coon, Goldberg, Rogers, and Tucker (2001) set out to test whether routine television viewing during mealtime caused a variation in overall food consumption patterns of young children. In a study of 91 parent-child pairs, they found that children from families who watched television during at least 2 meals per day derived 5% more of their energy from pizza, salty snacks, and soda than those children from families in which television viewing was not a normal part of the mealtime routine. In addition, those same children derived nearly 5% less of their energy intake from fruits and vegetables than the children in low television use families (Coon et al., 2001).

Coon and colleagues' (2001) study implies that television viewing is a powerful influence on a child's eating behavior and needs to be addressed when developing appropriate recommendations for frustrated parents of neophobic toddlers. It is necessary to reiterate to these parents that their child may demonstrate improved mealtime behaviors if the television is turned off when sitting at the table. We know that toddlers are easily enticed by the bright colors and loud noises in commercials and may, therefore, choose not to eat the food provided to them in lieu of demanding what they see on the television. A simple remedy to this is to recommend that mealtime be television free.

The structure of the family meal, that is whether or not the family partakes in meals together, is an important aspect to obtain in the information gathered from the parents of a picky eater. It has been well evidenced throughout this paper that family members, particularly the toddler's parents, exert a huge influence on the eating habits and behaviors of young children. We know that the habits that parents help their children to develop in childhood will influence patterns children demonstrate as they grow up. The family meal is an invaluable time for children to learn what nutrition is and to follow their parents' modeling. Research has shown that meals prepared in the home tend to be higher in fiber, calcium, and iron, and contain less fat, saturated fat, cholesterol, and salt than meals obtained outside the home (Stockmyer, 2001). If children are exposed to these healthier foods during family mealtimes in toddlerhood, they may be more apt to continue these healthy habits in adolescence and adulthood. In addition to improving the intake of nutritious food, the family dinner provides an avenue to give the toddler structure and security. It is a time to foster stronger relationships and to improve family function. It is important to reiterate all these points to parents of picky eaters when recommending the implementation of the family dinner.

Though the toddler years are filled with challenges and frustrations, it is important to help parents focus on the positive and exciting developmental milestones their youngsters achieved. Young children engage in the picky eating habits and the negative mealtime behaviors as a means of demonstrating a sense of control and autonomy over an environment that is very new and scary to them. Parents struggle to provide the tools necessary for their children to grow into healthy, well-adjusted adults. Our responsibility as primary care providers is to offer the families of our small patients the methods and suggestions needed to encourage behaviors to achieve the goals of healthy nutrition and good mealtime behavior. The parent handout (see Table 1) lists recommendations based upon the current literature that may provide effective ways to achieve adequate dietary consumption patterns. An annotated bibliography of lay books published in recent years may also be of interest to parents seeking additional nutritional understanding (see Table 2). By using what we know and offering solid advice to the families of these toddlers, we will foster an atmosphere of trust, honesty, and well being that will be reflected in the good health of all our patients.

CE Information

The print version of this article was originally certified for CE credit. For accreditation details, contact the publisher, Janetti Publications, Inc., East Holly Avenue Box 56, Pitman, NJ 08071-0056

Tables

Table 1. Parental Handout

What to Do With That Picky Eater

This is an exciting time in your toddler's life. He or she is constantly exploring the world and learning new activities. Your toddler is becoming more talkative and expressive, while gaining the ability to ask for and demand the things he or she wants. Essentially, your toddler is beginning to gain a sense of independence and separateness from you. Though this is exciting, it can be filled with frustration when your decisions and your desires are not the same as those of your toddler. Some of the most difficult situations may arise at meal and snack times when your toddler may refuse to eat or prefer to play rather than sitting at the table. These situations may seem unmanageable to you as a parent, but by understanding the reasons why picky eating occurs, you can begin to implement simple strategies to improve your child's eating behaviors.

What Do We Know about Picky Eating?

· A toddler is not growing as rapidly as he or she did in the first year of life. Therefore, a toddler may have a decrease in appetite resulting in decreased consumption of food. This will generally be reflected in a decrease in eating at meals and snack times.

· Young children possess an automatic mechanism that helps them regulate how much they ingest so they can sustain growth. In other words, when left to their own devices, a toddler will eat enough to give his or her body what it needs to grow.

· The introduction of new foods to a toddler can be a scary experience. We, as adults, know that it may take several tries to become comfortable with a new experience. Young children are no different when it comes to trying new foods. Toddlers may require frequent exposures to a new item before they will accept it.

· A toddler is just beginning to recognize himself or herself as a separate person from the parent and is struggling to gain some independence and control over the environment. He or she may attempt to gain this independence and control by testing the limits imposed by the parent, especially during mealtimes.

· Toddlers' eating patterns are influenced by the eating behaviors of their parents, siblings, and peers. The popular phrase, "children have a mind of their own," does not always hold true for the dietary decisions made by a toddler. The way you eat and the food choices you make will affect the choices your toddler makes.

Strategies to Make Meals and Snack Times More Enjoyable For You and Your Toddler

· Offer your toddler 2-3 food choices at snacks or meals. This allows your child to have some control over his or her eating patterns by choosing what to eat.

· Provide your toddler with appropriate smaller servings of foods so he or she does not feel overwhelmed. This may be a couple of tablespoons of vegetables or meat, or a half of a piece of fruit. Toddlers feel a sense of independence when they can finish all their food and ask for more.

· Give your toddler the appropriate equipment for eating. In other words, provide them with small utensils, plastic cups, and plates with a lip to allow food to be more easily scooped. Do not forget to seat your toddler in a position that allows him or her to reach everything easily and independently. Position your toddler's feet so they are supported and not dangling.

· Allow your toddler to develop his or her own tastes at his or her own pace. It may take ten or more exposures to a new food before a toddler will accept it. Be patient with this process.

· Your toddler will develop personal favorite foods. Make these foods occasionally, but resist the urge to make them all the time. Preparing your toddler's favorite meal all the time will encourage those picky eating habits and may lead to the avoidance of entire groups of foods.

· Schedule meals and snacks for approximately the same time each day. Toddlers need a routine and they should be expected to be cooperative with that schedule.

· Do not eliminate snacks between meals with the expectation that the toddler will eat more at the next meal. Toddlers do not understand the physical discomfort of hunger pains and may become irritable if snacks are eliminated.

· Make mealtimes family times. Eat at the table together and expect your toddler to sit with the family whether or not he or she is interested in eating. Research has demonstrated that eating dinner as a family has beneficial effects on diet quality and food choices later in life.

· Turn off the television and put away the games at mealtime. The toddler needs to have undivided attention for the task of eating and will tend to be more cooperative with sitting at the table if not distracted.

· Do not force your toddler to eat by punishing or threatening him or her. Your toddler is trying to assert his or his independence by testing the limits you have provided. Punishing the child or threatening to punish the child will only result in a power struggle that will worsen the picky eating habits.

· Give your toddler juice or milk as a part of meals and snacks. Offer him or her water in between these times. Toddlers require no more than 16-24 ounces of milk a day and should be limited to no more than 4-6 ounces of juice per day. Allowing a child to fill up on juice and milk throughout the day will cause a decrease in appetite, so the child may eat even less at meal times.

Meal and snack times should be fun and enjoyable for both you and your toddler, not times of frustration and irritation. By using a few of these simple suggestions, you will help improve your child's picky eating habits. Remember, you are your toddler's very best role model. Your healthy eating habits and your patience are the best way to ensure that your toddler develops healthy eating behaviors that will last a lifetime!

Table 2. Books for Parents of Picky Eaters

Elbert, P. (2001). Dr. Paula's good nutrition guide for babies, toddlers, and preschoolers. Cambridge, MA: Perseus Publishing.

There are three chapters on each of these age groups followed by general nutrition information. Letters from parents in her practice who ask feeding questions are followed by answers from Dr. Paula, a pediatrician. [$14.00]

Ellison, S., & Gray, T. (1995). 365 foods kids love to eat. Napierville, IL: Source Books, Inc.

This is a good recipe book encouraging children to eat nutritiously from baby foods, beverages, snacks, breakfast, sandwiches to salads, and more. Sections are included on healthful food substitutions and table management suggestions. [$12.95]

Karmel, A. (2001). The healthy baby meal planner. New York, NY: Simon and Shuster.

An accomplished cook (Cordon Blue School of Cooking graduate), the mother of three, and author of three other cookbooks provides interesting nutritional gourmet recipes for children 4 months through toddlerhood with basic information on nutritional needs. If toddlers will not eat, she suggests refrigerating the food for later. She also reinforces that toddlers like repetition, to assist with preparation, and an attractive presentation. She also encourages explaining that this is the meal and suggests providing nothing else. [$16]

Sears, W., & Sears, M. (1999). The family nutrition book. Boston, MA: Little, Brown, & Company.

A physician and nurse couple present a comprehensive guide on nutrition with information in the first chapters about fat, cholesterol, sugar, proteins, calcium, iron, vitamins, fiber, and water. The next three sections are on making wise food choices, feeding the picky eater, and trimming the family fat. This is a good reference for all nutrition questions in a family. Tips for feeding toddlers are given: offer a nibble (ice cube) tray, dip it, spread it, top it (cheese, peanut butter, yogurt), dunk it, cut it up, pack it, (AU: MAKE A?) veggie vendor, share it, respect tiny tummies, make it accessible, sit-still strategies, turn meals upside down, let them cook, make every calorie count, count on inconsistency, and relax. [$18.95]

Swinney, B. (1999). Healthy foods for healthy kids: A practical and tasty guide to your child's nutrition. New York, NY: Meadowbrook Press.

This registered dietician provides nutritional information in the first section and what to feed each age group in the second section. She includes discussions on each of the four food groups, snacks, eating out, and convenience foods with recipes scattered throughout the book. [$12]

Tarlou, J.M. (2001). The "everything" baby's first food book. Holbrook, MA: Adams Media Corporation.

As a food writer in the food industry, Tarlou was motivated to write this book when her own son became 8 months old and she began researching baby foods. Her son then turned into a "picky eater" toddler, and she knew that families needed such information. The book, which is loaded with accurate information, is easy to read and well written. [$12.95.]

Ward, E. (2002). Healthy foods, healthy kids: A complete guide to nutrition for children from birth to 6 years old. Avon, MA: Adams Media Corporation.

This book, written by a nutritionist, is a little more dense reading than the other books but is accurate and includes comprehensive with age-specific recommendations for 0-6 years of age. [$14.95]

Yaron, R. (1998). Super baby food (2nd ed., Revised). Peckville, PA: F.J. Roberts.

The authors discuss feeding from starting solids at 6 months through 3 years of age. The book provides rationale for good nutrition along with baby food preparation and storage followed by suggestions for feeding the toddler. Recipes (350) are included throughout. [$19.95]

References

American Academy of Pediatrics (AAP). (2001). The use and misuse of fruit juices in pediatrics. Pediatrics, 107, 1210-1213.

Birch, L.L. (1998). Psychological influences on the childhood diet. The Journal of Nutrition, 128, 407S-410S.

Birch, L.L., & Fisher, J.A. (1995). Appetite and eating behavior in children. Pediatric Clinics of North America, 42, 931-953.

Birch, L.L., & Fisher, J.O. (1998). Development of eating behaviors among children and adolescents. Pediatrics, 101, 539-549.

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Mary Cathey, MSN, BS, is Pediatric Nurse Practitioner, Oak Ridge Pediatric Clinic, Oak Ridge, TN.

Nan Gaylord, PhD, RN, is Assistant Professor, College of Nursing, University of Tenessee, Knoxville, TN.