We read with interest the article by Zucker et al,1 “Psychological and psychosocial impairment in preschoolers with selective eating.” The authors reported that moderate and severe selective eating (SE) were associated with current and future psychological symptoms, and that “findings suggest that health care providers should intervene at even moderate levels of SE.” We believe that the reported data do not support these conclusions.
The authors deem this study population to be a “community sample,” but the participant selection process yielded a population not representative of most communities. After screening 3433 primary care patients, the authors selected all 943 patients deemed at high risk for anxiety disorder and a small random selection (n = 189) of the remaining, low risk patients yielding a final sample where 83% were at high risk. The study sampling frame was appropriate for the authors’ original study on anxiety, but not appropriate for a study of SE. Despite the authors’ application of sampling weights, we remain concerned about the stability of study estimates, given the small size of their low-risk sample and the low frequency of SE and measured outcomes. Even with sampling weights applied, the prevalence of anxiety and other disorders presented in Table 2 is two- to ninefold higher than other studies using a similar primary care population and the same diagnostic tool.2
Moderate SE was defined as a child eating “only within the range of his/her preferred foods,” without clarifying the degree of restriction or chronicity. Most children are a little hesitant to eat something they have not eaten before. Without a precise definition of moderate SE, and no comparative “mild SE,” we cannot ascertain whether moderate SE was developmentally inappropriate.
The authors’ statement that their “findings suggest that health care providers should intervene at even moderate levels of SE” is not supported by their data. There were no statistically significant differences between the no SE and moderate SE groups for any psychiatric diagnosis (Table 2), and the statistically significant differences in symptom count (Fig 2) are of debatable clinical significance. If a medical condition underlies the SE, the symptoms described in Fig 2 may be a natural response that could improve with treatment of the underlying condition. Finally, the authors did not control for potential confounders such as maternal anxiety, which could influence both a child’s predisposition for anxiety disorders, as well as the parental report of both SE behaviors and psychiatric symptoms.
The authors assert that “the term SE (or ‘picky eating’) is now obsolete. If an individual presents to primary care with the presenting problem of SE, then impairment is implied.” Our interpretation of these data is that, among children predisposed to anxiety, SE may represent impairment and another manifestation of underlying psychopathology. To support the authors’ assertion that all picky eaters presenting to primary care are at substantially greater risk of worrisome psychopathology requiring intervention, a cohort study that is truly representative of the general population must be conducted. We hope this study stimulates further research in this area.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
- Copyright © 2016 by the American Academy of Pediatrics