Picky eating in children may be linked to autism and ADHD: a large study in Norway
A child's first "crankiness at the table" sometimes turns out to be more than just an age-related milestone
Psychologists at the University of Oslo have followed tens of thousands of Norwegian families and identified a notable group of children in whom food selectivity and avoidance persisted for many years and were associated with more frequent developmental disorders and certain genetic features. About it writes Justin Jackson for the publication Medical Xpress.
The study is published in the journal JAMA Pediatrics.
When "just being picky" is no longer the norm
Many toddlers:
push their plate away,
don't try new foods,
eat only a couple of "allowed" foods.
Previously, "food fastidiousness" has been described in about 10-15% of children at various ages in early childhood and about 5.5% if it persists longer. But there is a more serious condition - avoidant/restrictive food patterns, which include:
low interest in food,
intense sensitivity to taste or texture,
fear of discomfort or choking,
very limited volume or variety of foods.
Some of these cases fall under the diagnosis of avoidant/restrictive food intake disorder (ARFID), an avoidant/restrictive eating disorder in which eating is not associated with weight or figure concerns but is already leading to nutrient deficiencies, inadequate weight gain and energy.
Who was studied and how
The authors used data from the large national Norwegian Mother, Father, and Child Cohort Study (MoBa):
about 114,500 children,
95,200 mothers, and 75,200 fathers,
~80% of participants had genetic data (from mother's blood and child's cord blood).
For the main analyses, 35,751 children were selected for whom data on food avoidance/restriction at 3 and 8 years of age were available. Approximately equal proportions of girls (49%) and boys (51%).
The assessments were:
eating behaviour at 3 and 8 years of age (questionnaires),
data from national registers on diagnoses (nutritional problems, growth problems, deficits, neurological and psychiatric disorders).
How problematic eating patterns were defined
The researchers identified two levels:
ARFI-broad level - if at least one symptom of food avoidance/restriction was expressed at 3 and/or 8 years of age.
Examples of items: "doesn't eat well", "very picky", "you have to try hard to make sure the child eats enough", "gets full easily", "eats very slowly", "eats less when upset or angry".Children with symptoms at 3 or 8 years of age were further divided into three groups:
persistent - symptoms at both 3 and 8 years of age;
transient - only at age 3;
emergent - only at 8 years of age.
ARFI-clinical - ARFI-broad + at least one sign of clinical significance:
inadequate weight gain,
BMI below the 5th percentile,
growth retardation,
severe or unspecified protein-energy deficiency,
diagnoses of "eating disorders" or vitamin deficiencies, etc.
How common it is
Of the 35,751 children:
11,468 (32.1%) had at least one ARFI-broad symptom at 3 and/or 8 years of age;
24,283 (67.9%) had no such symptoms.
Among the entire sample:
6.0% of children had persistent ARFI-broad (symptoms at both 3 and 8 years);
17.7% - only at 3 years of age (transient);
8.4% only at 8 years of age (late).
When clinical significance was taken into account:
2,265 children (6.3%) met ARFI-clinical criteria;
1.8% - persistent clinical variant;
3.2% - transient;
1.4% - late.
The "clinical level" was most often set by weight loss or growth problems. Among persistent ARFI-broad, 22.6% had such problems; among transient, 14.9%; and among late ARFI-broad, 12.1%.
Not just at the table: links to development and diagnoses
Children with persistent food avoidance/restriction problems differed from their peers in more than just eating behaviour.
According to questionnaires from infancy to 14 years of age, they had:
had more difficulties with eating,
more speech and motor problems,
higher levels of emotional difficulties,
more symptoms of inattention and hyperactivity,
more stereotyped and repetitive behaviour,
more aggressive or uncooperative behaviour.
By age 14, adolescents with persistent ARFI-broad were also less likely to exhibit prosocial behaviours (helping others, empathy) compared to the group without ARFI.
They were also more likely to have diagnoses of:
autism - in 5.5% (vs. 1.7% in the non-ARFI-broad group);
ADHD - in 9.5% (vs. 5.3%);
epilepsy - in 2.25% (vs. 1.33%);
mental retardation and global developmental delay - also markedly more common than in children without ARFI.
Children with transient or late patterns tended to occupy an intermediate position.
Genetics: the contribution is there, but it's not decisive
The authors used genome-wide association analysis (GWAS).
At 3 years of age, the combined contribution of common genetic variants explained about 8% of the ARFI-broad variance.
At 8 years, it was about 12%.
For clinically significant cases (ARFI-clinical) - about 16%.
Genetic patterns overlapped with:
cognitive ability and educational attainment (higher ARFI risk - lower genetic "tuning" for high performance);
lower childhood and adult BMI;
eating preferences (less inclination towards low-calorie and 'unsweetened' foods, more inclination towards sweet caffeinated beverages);
risk of inflammatory bowel disease, colitis, celiac disease;
risk of ADHD.
Some of the same variants were associated with ARFI at 3 and 8 years of age, suggesting a stable genetic background.
What this means for parents and doctors
The study shows:
selective, avoidant eating in children is quite common,
in a notable proportion it persists for years and has clinical consequences,
stable patterns are often associated with other developmental difficulties and somatic problems(growth, GI).
Genetics explains only part of the picture, between 8% and 16% of the variation. This means that environment, upbringing and early support also play an important role.
The authors emphasise the need for:
attention to persistent eating problems (not just "will outgrow it in time"),
early identification of children with persistent selectivity,
comprehensive care - involving paediatricians, psychologists, nutritionists and, if necessary, neurologists and psychiatrists.