A 4-year-old girl is brought to the office due to "picky eating." Her mother says, "She insists on eating the same thing for dinner every night. First it was fish sticks for a few weeks, and now she's switched to pasta with cheese. She starts crying if I suggest trying something different." The patient eats yogurt for breakfast and takes peanut butter sandwiches and apple wedges to preschool for lunch; she refuses to eat unless the sandwich is cut into triangles and the apple skin is peeled. The patient's teacher has reported that she interacts with other children for group activities but tends to play with one specific girl during free time. She is toilet-trained and able to tie a knot but cannot tie her shoelaces or dress herself. The patient can draw a square and catch a ball. Vital signs and physical examination are normal. She is tracking on the 70th percentile for weight and 60th percentile for height. The patient makes intermittent eye contact with the physician, and when asked about her favorite foods, she smiles and tells a story about how owls are the smartest animals in the forest. What is the most likely explanation for this patient's behavior?

Question

A 4-year-old girl is brought to the office due to "picky eating."  Her mother says, "She insists on eating the same thing for dinner every night.  First it was fish sticks for a few weeks, and now she's switched to pasta with cheese.  She starts crying if I suggest trying something different."  The patient eats yogurt for breakfast and takes peanut butter sandwiches and apple wedges to preschool for lunch; she refuses to eat unless the sandwich is cut into triangles and the apple skin is peeled.  The patient's teacher has reported that she interacts with other children for group activities but tends to play with one specific girl during free time.  She is toilet-trained and able to tie a knot but cannot tie her shoelaces or dress herself.  The patient can draw a square and catch a ball.  Vital signs and physical examination are normal.  She is tracking on the 70th percentile for weight and 60th percentile for height.  The patient makes intermittent eye contact with the physician, and when asked about her favorite foods, she smiles and tells a story about how owls are the smartest animals in the forest.  What is the most likely explanation for this patient's behavior?

Quizplus · Accepted Answer

Although this child has specific food preferences, she generally eats a variety of foods (yogurt, cheese, pasta, fish, peanut butter, apples) and is tracking adequately on her growth curves. Young children often have certain preferences for individual foods or food groups or have sensitivities to the taste, shape (eg, cutting up sandwiches into triangles), texture (eg, peeled apple skin), or smell of foods. This, together with a growing sense of autonomy, may result in picky eating, which can manifest as a preference for a particular food or an aversion to trying new foods. Offering the child a variety of fresh foods and eating the same meals as the child can be helpful. If picky eating is accompanied by rigid behaviors, poor growth, weight loss, or developmental delay, then further evaluation for an underlying disorder is indicated. (Choice A) In autism spectrum disorder, certain foods may be avoided due to sensory sensitivity. This is accompanied by repetitive behaviors, fixed interests, and difficulty interacting with others, which this patient does not display. (Choice B) In avoidant/restrictive food intake disorder, there is a dislike of eating due to the sensory experience of eating or a fear of the consequences of eating (such as fear of vomiting or choking); it is associated with significantly poor growth or weight loss. (Choice D) Obsessive-compulsive disorder may be associated with food-related obsessions or compulsions, such as the need to separate food items on a plate (with no contact between different items), eat a precise amount of food, or count a certain number of times before eating. The behaviors are often repetitive, distressing, and disabling, with patients having little control over them. This patient's refusal to eat apples that are unpeeled and sandwiches that are not cut in triangles is a reflection of her picky eating. (Choice E) Oppositional defiant disorder (ODD) presents with a pattern of irritability or anger together with defiant behavior. This child does not have an angry or irritable mood, and her refusal to comply with her mother's requests is isolated to food choice and not pervasive as in ODD. (Choice F) Four-year-olds are able to play imaginatively with others and tell stories (eg, about owls being the smartest animals in the forest). They tend to be self-centric and may not be interested in answering other people's questions, as in this case. They often have a preferred friend, developing a group of friends around age 5. If a child has poor eye contact, lack of social engagement, or lack of imaginative play or storytelling, then a social-emotional delay could be considered. Educational objective: Young children often prefer particular foods or food groups, which is consistent with normal development. However, when picky eating is accompanied by behavioral rigidity, poor growth, weight loss, or developmental delays, further evaluation is indicated. References: Time to re-think picky eating?: a relational approach to understanding picky eating. (http://www.ncbi.nlm.nih.gov/pubmed/28476160) A narrative review of childhood picky eating and its relationship to food intakes, nutritional status, and growth. (http://www.ncbi.nlm.nih.gov/pubmed/30558328) Picky eating in children: causes and consequences. (http://www.ncbi.nlm.nih.gov/pubmed/30392488)

A 4-Year-Old Girl Is Brought to the Office Due to "Picky