Diet fortification for mild and moderate picky eating in typically developed children: Opinion review of Middle East consensus

Table 1 Protocol for identifying and managing children with mild-to-moderate picky eating in the Middle East

Topic	Protocol recommendations
Identifying the picky eater	Picky eaters are “children who consume an inadequate amount and variety of foods through rejection of foods that are familiar, as well as unfamiliar, to them”
	Mild picky eating was defined as inadequate food consumption and/or poor diet quality and/or variety without over- or undernutrition or evidence of micronutrient deficiencies
	The moderate picky eating definition resembled the mild picky eating in food intake pattern but with over- or undernutrition or evidence of micronutrient deficiencies
Evaluating the picky eater	Once identified, a picky-eating child should be systematically screened for nutritional risk
	Assessing the growth pattern using a growth chart alone is not enough to identify the severity of nutritional risk, as many of the children showed a normal growth curve; in addition, a nutrition screening tool (i.e., nutrition screening tool for every preschooler, nutrition screening tool for every preschooler-toddler) should be used to identify the severity
	Organic red flags include: (1) Unintentional weight loss or failure to thrive; (2) Feeding difficulties with gastrointestinal symptoms; (3) Oral-motor issues impacting eating; (4) Nutritional deficiencies or signs of malnutrition, concurrent medical conditions (e.g., gastrointestinal disorders); (5) Dysphagia; (6) Aspiration; (7) Apparent pain with feeding; (8) Diarrhea and vomiting; (9) Developmental delay; (10) Cardio-respiratory symptoms; and (11) Growth faltering
	Behavioral red flags include: (1) Food fixation; (2) Noxious (harmful or unpleasant), for example, forceful feeding; (3) Abrupt cessation of feeding after a trigger event; (4) Anticipatory gagging; (5) Persistent refusal to eat or extreme food aversions; (6) Behavioral challenges during mealtime (tantrums, anxiety); (7) Avoidance behaviors related to food; and (8) Emotional distress during mealtimes
Behavioral strategies	It is important to provide parents and caregivers with feeding and behavioral strategies that can be implemented for both mild and moderate picky eaters
	The panel suggested providing parents/caregivers with some feeding rules and behavioral strategies for the management of childhood picky eating as follows: (1) Serve age-appropriate portions; (2) Get children acquainted with foods through meal planning and preparation; (3) Involve children in menu planning; (4) Provide healthy food choices to children (e.g., fruits, vegetables, and other healthy snacks); (5) Avoid the power struggle; (6) Give kids the opportunity to participate in food preparation (let children touch, smell, and feel food); (7) Abstain from labelling children; (8) Build up on progress as it occurs; (9) Regularly expose children to new foods; (10) Avoid bribing children to eat; (11) Be wary of over-snacking; (12) Establish bottom-line limits; (13) Become a positive role model to children; and (14) Given enough time for children to change their eating habits
Nutritional intervention	Nutritional management of mild and moderate picky eaters should include diet fortification through the food-first approach. However, it can be challenging to implement these strategies in the Middle East
	Time constraints for meal preparation and working mothers, nannies, or other caregivers assigned to meal preparation are some of the nutrition challenges faced in the Middle East
	Nutritional management of mild and moderate picky eaters should include diet fortification through the food-first approach. However, it can be challenging to implement these strategies in the Middle East
	Unfortunately, according to the available data, the Middle East region suffers from micronutrient deficiency that needs an immediate solution to improve children’s health. However, the use of dietary supplements in the region is low, and adherence is poor
	Dietary supplementation provides an individually targeted approach to addressing micronutrient inadequacies and deficiencies
	Commercial food fortification in the Middle East has been sporadic and ineffective
	The diet of picky eaters can be fortified using a food-first approach and oral nutritional supplements
	Oral nutritional supplements, in liquid and powder forms, can be used to fortify the food of mild and moderate picky eaters in a much easier way
	Ultimately, in mild and moderate picky eaters, offering liked foods with enhanced nutritional value through a food-first approach or using oral nutritional supplements can help meet the child’s nutritional requirements for growth and development, stop the food fight, and soothe the parent-child relationship