Nutritional Status and Nutrient Intake of Children With Feeding Disorders in Early Childhood

Introduction

Pediatric feeding disorder (PFD) is a multifactorial condition of early childhood arising from the interaction of medical, nutritional, feeding skill, and psychosocial factors. Avoidant/restrictive food intake disorder (ARFID) is an eating or feeding disorder that manifests as a persistent failure to achieve adequate nutrient and/or energy requirements and is associated with at least 1 of the following symptoms: significant weight loss (or lack of expected weight gain), significant nutrient deficiencies, enteral feeding or oral nutrient supplementation due to inadequate intake, and marked impairment of psychosocial function [1].

Even in early childhood, under the age of 3 years, proper nutrition is of paramount importance, as this is also the age of rapid physical growth and maturation of the central nervous system [2].

A large part of eating habits and taste preferences are formed in the early years of life [3]. Inadequate energy and nutrient intake affects children’s short- and long-term health and development and influences the development of later noncommunicable diseases [2]. Nutritional problems over a longer period of time can lead to nutrient deficiencies [1].

Eating disorders in infancy and toddlerhood are increasingly common in pediatric practice [1]. Between 25% and 45% of typically developing children and up to 80% of children with developmental disorders have some type of eating disorder [4]. Like other early childhood mental health problems, the background to feeding disorders is thought to be influenced by complex mechanisms [5]. Approximately 30% of children have mild feeding difficulties. The prevalence of clinical eating disorders is 3% to 10%, and approximately 3% to 4% for severe disorders [6].

The diagnosis of eating disorders is not standardized, as both the International Classification (BNO) and the Diagnostic and Statistical Manual of Mental Disorders (DSM) classification system are used. It should be emphasized that a new category, ARFID has been added to the DSM-5 classification system [7].

The DC: 0–5 Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood diagnostic system is grounded on a developmental-psychopathological approach and early childhood mental and psychological health promotion from an Infant and Early Childhood Mental Health (IECMH) perspective [8]. The IECMH is an evidence-based multidisciplinary specialty with the fundamental principle that in the early years of life, across the continuum of care, children are best understood in their relationship with their primary caregiver [9]. The DC: 0–5 system puts children’s problems and symptoms in a multifactorial context using a 5-axis system, consisting of clinical disorders, relational context, general health conditions and factors, psychosocial stressors, and developmental competencies. It distinguishes 3 subgroups of eating and feeding disorders: overeating, reduced food intake, and atypical eating disorders [8]. The first version of the DC: 0–5, renewed in 2016, was DC: 0–3 Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood, published in 1994 by ZERO TO THREE. This was followed in 2005 by the revised edition of DC: 0–3R [10]. DC: 0–3R can be highlighted as a complex diagnostic system, based on extensive literature and clinical experience.

The World Health Organization (WHO) has developed a comprehensive definition of PFD as an age-inappropriate oral intake due to organ failure, nutritional deficiency, poor eating skills, and/or psychosocial dysfunction [11].

The etiology of eating disorders is complex, requiring an advanced interdisciplinary approach to the investigation and treatment of eating problems in infants and young children under 3 years of age [12,13]. Feeding disorders can require hospitalization, as not all eating disorders can be treated on an outpatient basis [6].

Early childhood disorders require a modern interdisciplinary approach to get the appropriate help to address problems with eating and sleeping. The working method is based on complex specialist care in close cooperation with different specialists, including a pediatrician, special needs educator, child psychologist, dietitian, and others. The use of this practice ensures that eating and sleeping disorders in early childhood are based on a biopsychosocial model [13,14].

Families who come to the early childhood eating and sleeping disorder clinic are seen by a dietitian several times during their stay. The most frequently asked question during a dietetic consultation is whether the child’s oral intake of food and fluids is adequate in terms of quantity and quality [13]. Determining a child’s energy and nutrient intake is a key part of optimal management [15].

Therefore, in the present study, we aim to evaluate the nutritional status and nutrient intake of children under 3 years of age diagnosed with PFD. By comparing nutrient intake with international recommendations and highlighting specific deficiencies, we seek to contribute to a better understanding of the dietary characteristics of this vulnerable population and to support the development of more effective clinical management strategies.

Material and Methods

ETHICAL APPROVAL AND STUDY DESIGN:

The cross-sectional study was conducted at the Early Childhood Eating-Sleep Disorder Outpatient Clinic of the Heim Pál National Pediatric Institute, Budapest, Hungary. The Institutional Ethics Committee of Pál Heim Children’s Hospital approved the study (authorization number: KUT 1/2017, date: January 27, 2017). Participation required written informed consent from a parent or legal guardian. The study was conducted in accordance with the principles of the Declaration of Helsinki.

PARTICIPANTS AND SAMPLING:

Forty children under the age of 3 years diagnosed with PFD participated in the study. Participants were enrolled in the study between May 2023 and August 2025. The inclusion criteria were as follows: age between 6 and 36 months, diagnosis based on the PFD criteria, and active care in outpatient settings. Exclusion criteria included severe chronic diseases, incomplete data sheets, and lack of parental consent. Our study was primarily exploratory in nature. When determining the sample size, we considered the sample sizes of similar international studies [16]. Participants were divided into 2 age groups based on the recommendations of the European Food Safety Authority (EFSA) [17]: infants aged 6 to 12 months and young children aged 1 to 3 years.

DIAGNOSTIC FRAMEWORK:

During clinical practice, diagnostic classification was based on BNO 11. Feeding disorders were categorized according to the diagnostic criteria for PFD [11]. No data were collected during the children’s acute illness. Other cases, such as food allergies or other chronic diseases, were marked as negative risk factors during the analysis.

RESEARCH QUESTION AND OBJECTIVES:

The aim of this research is to examine how PFD in early childhood affects the nutritional status and nutrient intake of children under 3 years of age compared with international dietary recommendations, with a particular focus on the adequacy of energy and nutrient intake, deviations, and potential deficiencies.

DATA COLLECTION:

In the study, a quantitative, self-completion questionnaire and a 3-day food diary were used for data collection, in which responses were voluntary and anonymous. The questionnaire was used to assess socio-demographic data, birth weight and length, and current weight, length, and head circumference, and to ask questions about eating habits and consumption of dietary supplements.

DATA ANALYSIS:

The data from the 3-day food diaries were analyzed using NutriComp 5.0 SPORT software, which was used to determine individual energy and nutrient intake. Nutrient intake data were recorded and analyzed in grams (g), milligrams (mg), micrograms (μg), kilocalories (kcal), per kilogram of body weight (g/kg), and as a percentage of energy intake (en%). During the analysis, we examined the following macro- and micronutrients: energy (kcal), carbohydrates (g, g/kg, en%), protein (g, g/kg, en%), fat (g, g/kg, en%), as well as the following vitamins and minerals: vitamin B1 (μg), vitamin B2 (μg), vitamin B6 (μg), vitamin B12 (μg), vitamin C (mg), vitamin D (μg), vitamin E (mg), vitamin K (μg), folic acid (μg), potassium (mg), calcium (mg), magnesium (mg), iron (mg), and zinc (mg). Parents and caregivers received detailed written and verbal instructions on how to complete the 3-day food diary, in which they had to record the exact time, quantity, and composition of meals. We also provided an instructional video to help them complete the diary, which was made available to them before the study.

Anthropometric measurements (body weight, height, head circumference) were taken by trained health professionals, primarily public health nurses and pediatricians, during outpatient visits. Body weight was measured on certified scales, and body length and head circumference were measured with a tape measure, in accordance with the recommendations of the WHO and UNICEF [18].

Eating habits and dietary supplement use were assessed using a self-administered questionnaire. The questionnaire collected socio-demographic data, birth parameters (weight, length), and current anthropometric data. Questions also covered eating habits, meal circumstances, and any feeding-related concerns. Regarding dietary supplements, parents and caregivers were asked: Are you currently following a special diet? If yes, what kind? Do you or your child take any dietary supplements? If yes, what kind (name, brand), in what amount, and who recommended it? Where did you obtain it? Examples of common responses included vitamin D, vitamin C, calcium, folic acid, and multivitamin products purchased from pharmacies or drugstores. During data analysis, we examined the frequency of supplement use. Dietary supplement intake was not included in the nutrient analysis derived from the 3-day food diaries.

METHODOLOGICAL BACKGROUND:

An important consideration in the design and implementation of the study was the comparability of the results with the international recommendations of the EFSA. The WHO standards include mainly 4 indicators: weight for age, length/height for age, weight for height/length, and body mass index. Weight for age is an indicator of children’s short-term and long-term nutritional status. Length/height for age is an index to judge children’s long-term malnutrition. Weight for height/length is an index of acute malnutrition [19]. The percentile curve was used to track the children’s weight and height development to determine nutritional status. In addition, the children’s current percentile value was recorded separately at completion of the food diary [20]. To establish the nutrient intake, the obtained values were compared with the recommended intake for each child. We compared our results with internationally accepted recommendations; therefore, we did not form a separate control group [17]. However, we also compared our results with those of a previous comprehensive Hungarian nutrition assessment of healthy children [2].

To evaluate the children’s average energy intake, we used the age-specific reference values for daily energy intake recommended by the EFSA [17]. Based on these guidelines, the recommended energy requirements were determined according to age, sex, and body weight. The daily energy intake obtained from the food diaries was then compared with the recommended reference values, allowing us to identify deviations between the actual and the recommended energy intake.

We used the WHO weight and height growth percentile curves to assess nutritional status and followed their direction during the examinations. In children with PFD, we took into account different growth patterns based on clinical observations. Abnormal growth was determined based on the intersection of the 2 percentile curves, in accordance with methods accepted in clinical practice [19,20].

STATISTICAL ANALYSIS:

Data from the 3-day food diaries were entered and analyzed using NutriComp 5.0 SPORT software to determine individual energy and nutrient intake. Each participant was assigned an anonymous code number, and the data were stored in Excel spreadsheets linked to these codes. Statistical analyses were performed using IBM SPSS Statistics 22. Descriptive statistics (mean, standard deviation, number of items, minimum and maximum values), and 1-sample and 2-sample t tests were applied.

Results

BASELINE CHARACTERISTICS:

The average age of the sample was 20±7.1 months (range: 7–36 months). The age distribution of the sample was as follows: 7–12 months (6 participants, 15%), 1–2 years (27 participants, 67.5%), and 2–3 years (7 participants, 17.5%). The average body weight measured on the slide was 10±2.5 kg (range: 6.7–15.8 kg), and the average body length was 82±9 cm (range: 68–98 cm). The sample consisted of 6 children aged 6 months to 1 year and 34 children aged 1 to 3 years, with a sex distribution of 60% boys and 40% girls.

Based on the diagnostic criteria for PFD, the feeding disorders of the children aged 6 to 36 months corresponded to those shown in Table 1. According to the PFD diagnostic criteria, 42.5% of the sample showed medical dysfunction, 100% showed nutritional dysfunction, 100% showed feeding skill dysfunction, and 72.5% showed psychosocial dysfunction.

NUTRITIONAL STATUS:

In the following section, data are presented for children in whom abnormalities were identified in the percentile growth curves. A percentile curve was considered abnormal if it fell below the 3^rd percentile (provided the child’s birth weight was not extremely low) or if, at any point, 2 percentile curves crossed the plotted curve, indicating a slowing in the child’s weight and length development that required attention.

For the whole sample, the percentile curve showed an abnormal difference in 10 participants. The weight development curves of 4 participants were below the 3^rd percentile, 5 participant’s weight development curves crossed 2 percentile curves, and 1 participant’s length development curve crossed 2 percentile curves. Furthermore, it should be highlighted that the weight development curve for 6 participants and the length development curve for 1 participant showed a slightly flattening percentile curve.

ENERGY INTAKE:

Here, we present the results of the children’s nutritional assessment. The average daily energy intake for the whole sample was 802±229.7 kcal (range: 509–1385 kcal). For the 6-month to 1-year age group, it was 653±83.1 kcal (range: 554–757 kcal), while for the 1- to 3-year age group it was 828±237.7 kcal (range: 509–1385 kcal). The detailed data on average energy and macronutrient intake by age group are presented in Table 2.

In both age groups, we investigated whether the average energy intake differed significantly from the recommended intake. The results of the 1-sample t test showed that the average energy intake of the age group under 1 year of age was significantly different from the recommended intake (t(6)=−4.35, P=0.004). The results of the 2-sample t test showed a significant difference in energy intake between the 2 age groups (t(40)=−3.31, P=0.003), although it is important to highlight the difference in sample sizes between the 2 age groups.

MACRONUTRIENT INTAKE:

The average energy intake from carbohydrate for the whole sample was 55.9±5.9 en% (range: 46.2–70.9 en%). For the 6-month to 1-year age group the en% was 53.7±4.4 (range: 49.6–61.8 en%), while for the 1- to 3-year age group the en% was 56.4±6.1 (range: 46.2–70.9 en%). Detailed data on carbohydrate intake for each participant can be found in Figure 1.

Within this energy intake, in the 6-month to 1-year age group, the energy from added sugar was 6.3±5.9 en% (range: 0–20.7 en%), and in the 1- to 3-year age group, it was 13.7±15 g (range: 0–59.8 g). Carbohydrate intake came mainly from refined sources (eg, baked goods, cereal, and sweets, such as cookies), while fruit and vegetable consumption was relatively low. In addition, cake and chocolate accounted for a significant proportion of sweets. We also reviewed the main food sources of carbohydrate intake, with the results showing that the primary sources were refined grains, such as bread, pastry, pasta, rice, and cereal; second were fruits, such as apples and bananas; third were sweets, including cake, chocolate, ice cream, and chocolate-almond spread; and last were vegetables, such as tomatoes, carrots, and baby foods.

Protein intake averaged 12.7±2.5 en% (range: 7.4–16.8 en%). By age group the results were as follows: 6-month to 1-year group: 11.1±3.25 en% (range: 7.8–16.7 en%) and 1- to 3-year group: 12.9±2.25 en% (range: 7.4–16.8 en%). Detailed data on protein intake are shown in Figure 2.

Protein intake in the sample came primarily from animal sources, including dairy products, meat, and meat products, while plant-based proteins contributed only a small portion of the diet. Infant formula was the main source of protein, followed by dairy products, such as yogurt, cheese, and cottage cheese, and then meat and meat products, such as chicken, pork, and cold cuts. Overall, 77.5% of children (n=31) consumed formula, with the most common types being Milupa Milumil and Sinlac (Nestle). Among meats, white meat (eg, chicken) was consumed most frequently, whereas red meat (eg, beef) and fish (eg, fish fingers) were rarely consumed. Commonly consumed meat products included cold cuts (eg, salami), sausages, and various liver pâtés.

Breastfeeding practices varied across the total sample of 40 participants. Breast milk consumption was observed in 20% of children (n=8). Five infants were not directly breastfed and received formula or expressed breast milk instead. In most cases (n=20), breastfeeding began without difficulty and lasted on average 5±2.4 months (range: 2–9 months). Exclusive breastfeeding occurred in 2 infants and lasted 4 to 5 months. In 13 cases, breastfeeding started with more difficulty, required formula supplementation, and lasted on average 6±7.1 months (range: 1–21 months). For 1 infant, no breastfeeding data were available. At the time of the study, 8 infants were still receiving breast milk.

The average daily energy intake differed between children consuming breast milk and those who did not. Children receiving breast milk (n=8) consumed 651±127.7 kcal/day (range: 509–887 kcal), whereas children not receiving breast milk (n=32) consumed 839.6±235.2 kcal/day (range: 549–1385 kcal). A 2-sample t test indicated a significant difference between the groups (t(40)=−3.07, P=0.0029), although the sample sizes differed considerably.

The average fat content was 30.9±6.2 en% (range: 16.5–43.5 en%), with 34.9±6.5 en% (range: 25.7–43.5 en%) for the 6-month to 1-year group and 30.2±5.9 en% (range: 16.5–42 en%) for the 1- to 3-year group. Detailed data on fat intake are shown in Figure 3. Fat intake came mainly from animal sources, such as dairy products (eg, cheese, margarine) and meat products, while intake of plant-based fats (eg, nuts, seeds) was very low. Meat and meat products were the primary food sources of energy from fat; followed by dairy products, especially cheese; and finally fats such as margarine and butter.

MICRONUTRIENT INTAKE:

The study assessed children’s vitamin and mineral intakes, the average values of which are detailed by age group in Table 2. Calcium and iron were of particular importance. The main sources of calcium intake were milk, dairy products, and infant formula, while iron intake came primarily from infant formula, meat and meat products, and, to a lesser extent, breakfast cereals.

In terms of micronutrients, the results of 1-sample t tests showed that the average calcium intake of the 1- to 3-year group was significantly different from the recommended intake (t(34)=−2.66, P=0.006). Furthermore, the average levels of iron intake of the under 1-year group (t(6)=−3.23, P=0.012) and the 1- to 3-year group (t(34)=−3.83, P=0.0003) were significantly different from the recommended intake.

OVERALL DISTRIBUTION OF NUTRIENT INTAKE:

In addition, we compared the nutrient intake obtained from the study with the percentage of the recommended intake. The detailed data are shown in Table 3 as percentages of recommended intake.

EATING BEHAVIOR:

During meals, observed children’s behavior was as follows: 40% of participants (n=16) showed some kind of distraction (eg, playing, watching TV) during meals; of these, 8 showed feeding in semi-sleep. The research examined the type of food accepted by consistency, revealing that 5% of participants (n=2) accepted and consumed only pulpy foods. These foods included fruit purees, dairy products, meat and vegetable baby foods, and homemade purees. However, their nutritional content did not always meet age-specific recommendations, meaning they were unable to provide the children with optimal nutrition.

Discussion

The results of the study showed that energy intake was below the EFSA recommendation in both age groups [17,21]. Energy intake was markedly lower than that reported in a survey of children aged under 3 years by Erdélyi-Sipos et al [2], in which no low intake was found in children under 1 year of age: 51% reported normal, and 49% reported high energy intake. Among 1- to 3-year-old children, low intake was also absent and high energy intake was present in 52% [2]. This is understandable, however, as children with feeding disorders eat less and consequently consume less energy. Our survey confirmed this. Low energy intake in children with PFD is a complex problem that can be attributed to a number of factors: the child’s biological and genetic predisposition, the parents’ feeding style and mental state, the quality of family relationships, and a wide range of environmental influences can all play a role. The treatment strategy requires an interdisciplinary approach, involving dietary interventions, such as nutritional enrichment and, in severe cases, enteral feeding.

In the present study, the average energy intake from carbohydrates was predominantly normal for both age groups (Figure 1) [17]. The energy intake from added sugars was in line with that reported by Erdélyi-Sipos et al [2]. The primary food sources of added sugars were sweets, such as cakes and chocolates. Similar to the observations of Szűcs et al [22], intake of added sugar was positively associated with consumption of ready-made and semi-prepared foods. Excessive sugar intake can have adverse effects even at an early age, contributing to the development of noncommunicable chronic diseases, such as obesity and metabolic syndrome, and can cause dental problems and nutrient deficiencies later in life [23].

Adequate carbohydrate intake, as shown by the results of Yong et al [24] and Schmidt et al [16], can be explained by the fact that children with feeding difficulties primarily accept and consume carbohydrate-rich foods (such as bread, pastries, and breakfast cereal), which makes carbohydrates the main source of their energy and nutrient intake. On the other hand, there is evidence that humans have an innate preference for sweet foods, which is why these foods are easily accepted and consumed by young children [25].

Based on the reference values set by EFSA [17], 95% of children aged under 1 year (EFSA recommendation: 1.48–1.65 g/kg) and 1 to 3 years (EFSA recommendation: 1.13–1.26 g/kg) in the present study fell within the high protein intake range. This is similar to the results of a survey in 2019 [2], which showed 100% of the children tested were in the high protein intake group.

High protein intake is probably due to the consumption of formula, as 77.5% of children in the present study consumed some form of formula on a daily basis, even in higher amounts. In most children with feeding disorders, the absence of breast milk and extensive formula supplementation is observed, resulting in a high reliance on formula. The duration and exclusivity of breastfeeding have a significant effect on infants’ energy and nutrient intake, as well as on their overall health status (eg, immune protection, growth, and development) [26]. Our results are supported by a study by D’Auria et al [27], which showed that standard infant formulas contain similar amounts of fat and carbohydrates as breast milk, but much more protein. We drew attention to the possible effects of excessive protein intake (such as kidney function and bone health). Based on this, it is extremely important to regularly monitor protein intake, plan a suitable diet, and adjust nutritional supplementation if necessary.

The consumption of infant formula contributes significantly to high protein intake. In addition, the Hungarian dietary recommendations suggest that a variety of nutrient-dense foods should be gradually introduced into the diet of infants and young children, which promotes the development of healthy eating habits and reduces dependency on formula. According to the methodological recommendations of the Hungarian College of Health Professionals, exclusive breastfeeding is necessary until at least 6 months of age, and complementary feeding should ideally be started at around 6 months of age, introducing individual foods gradually, with particular attention to the careful, stepwise introduction of allergens [28].

The energy from fat is significantly below the recommended intake (EFSA recommendation: 40 en%/35–40 en%) [17]. For fat intake, Erdélyi-Sipos et al reported similarly low intakes in their publication. For children under 1 year of age, there was no significant difference in the mean daily fat intake between the results of the 2 studies (30.6 g), but in the 1- to 3-year age group, the mean daily fat intake was significantly lower (45.9–53.9 g) than our data [2]. Low fat intake came mainly from animal sources, such as dairy products (eg, cheese, margarine) and meat products, while intake of plant-based fats (eg, nuts, seeds) was very low. Unsaturated fatty acids (eg, olive oil, avocado, salmon) have a beneficial effect on cardiovascular health and nutritional status, while excessive consumption of saturated (eg, butter, animal fats) and trans fatty acids (eg, processed foods) may increase the risk of developing cardiovascular disease later in life [29].

We investigated what might underlie the low fat intake and found that carbohydrates are the main source of energy and nutrient intake in children, as they primarily consume and accept carbohydrate rich foods (such as breads, pastries, cereals) [30].

Schmidt et al [16] also described carbohydrates (50 en%), including breads and sweets, as the primary source of energy intake. Similarly, in the study by Harshman et al [31], the main food sources of carbohydrate intake were refined cereals, but unlike the results of our survey, they had a specifically higher added sugar intake (97±6.6 g). In our study, white breads and meat products were identified as the primary food sources of sodium intake, similar to the report by Szűcs et al [22].

For micronutrients, we found differences in the intake of vitamin B6, vitamin D, vitamin K, calcium, magnesium, iron, and zinc, compared with the recommended intakes. Average micronutrient intake by age group is detailed in Table 2. The results of our research show, in line with many international studies, that feeding disorders are characterized by low micronutrient intake [32,33].

In the present study, vitamin B6 intake in the 1- to 3-year group was below the recommended intake of 700 μg/day [17]. Vitamin B6 intake levels were specifically lower than those reported by Erdélyi-Sipos et al (<1 year: 775.4 μg; 1–3 years: 1115.5 μg) [2].

Vitamin D intake levels were lower than expected for both the 6-month to 1-year and 1- to 3-year groups (EFSA recommendation: 10 μg/10 μg) [17]. In comparison, vitamin D intake levels were higher than those reported in the study by Erdélyi-Sipos et al [2] (<1 year: 4.35 μg; 1–3 years: 3.36 μg). This may be due to the frequent consumption of formula by children with feeding disorders to meet energy and nutrient needs. These findings are supported by study by Zhang et al [34], who found that vitamin D intake levels were higher in formula consumers than in non-formula consumers. In addition, 87.5% of the sample received vitamin D supplementation in the form of formula and/or a supplement [34]. Overall, it can be concluded that vitamin D supplementation is highly emphasized among children with feeding disorders.

For vitamin K, overconsumption was observed in both age groups (EFSA recommended 6 months to 1 year: 8.5 μg, 1–3 years: 12 μg) [17]. Contrary to several international studies reporting a risk of vitamin K deficiency [16], in our study, the higher average vitamin K intake remained within the safe intake range and cannot be considered clinically abnormal. Clinical concerns, however, arise in specific situations, such as during anticoagulant therapy. The higher values are likely due to more frequent consumption of processed foods, as well as the high intake of formula in children’s daily diet. This is consistent with previous research showing that formula-fed infants typically have higher vitamin K intake levels than do breastfed infants [35–37].

The folic acid intake in the 6-month to 1-year group and 1- to 3-year group was optimal, compared with the recommended intake levels of 40 μg and 50 μg, respectively, for these age groups [17]. Furthermore, the daily intake of folic acid was significantly lower than that in the previous study by Erdélyi-Sipos et al [2] (<1 year: 72.8 μg; 1–3 years: 109.1 μg). This may be because children with feeding disorders do not eat enough folic acid-rich foods. Sources of folic acid are vegetables, especially dark green leafy vegetables, but it can also be found in pulses, offal, such as liver, yeast, and fortified foods, such as breakfast cereals [38]. Similarly, several international studies have found insufficient vegetable consumption among children with feeding difficulties [24]. Infants have an innate biological response to reject bitter and sour tastes, which can lead to low fruit and vegetable consumption. This is of concern, as fruits and vegetables are a source of micronutrients necessary for the development of an immune response and a healthy gut microbiome [25].

Vitamin B12 (cobalamin) is a water-soluble vitamin that plays a key role in the proper development and function of the brain and central nervous system, and in the process of blood formation [17]. For vitamin B12, the average daily intake was found to be optimal (EFSA recommendation: 0.9 μg), probably due to the high intake of formula among the participants in this study. Also, it has been reported that only one-third of children have an intake of vitamin B12 below the recommended level [17]. Compared with levels found in the study conducted in 2019 by Erdélyi-Sipos et al [2], the average daily intake of vitamin B12 in the present study was higher in the under 1-year age group (1.19 μg) and lower in the 1- to 3-year age group (2.51 μg).

It can be assumed that the optimal intake of some vitamins and minerals in spite of low energy intake in the present study was due to the consumption of formula, as formula contains small doses/quantities of the recommended daily intake levels of nutrients. For minerals, differences were found in the intake levels of calcium, magnesium, iron, and zinc. Calcium intake is essential for proper bone formation and development [17]. In our study, calcium intake was adequate in the under 1-year group (EFSA recommendation: 400 mg) and low compared with the recommended intake in the 1- to 3-year group (EFSA recommendation: 600 mg) (Table 2). Compared with the results of the 2019 survey [2] (<1 year: 466 mg; 1–3 years: 633 mg), our values were lower. The high rate of children’s daily calcium intake below the limit is due to insufficient daily intake of milk and dairy products. Torres et al [39] similarly reported that food selectivity leads to calcium intake below recommended levels in children with neophobia. In addition, insufficient intake of milk and dairy products can also result from the use of a dairy-free diet, which is often observed in children with feeding disorders [40]. We investigated whether this might be a factor in our own survey and found that only 3 participants out of 40 were on a dairy-free diet.

Magnesium intake in the 6-month to 1-year group was below the reference intake of 80 mg/day. For the 1- to 3-year group, the daily intake of magnesium was in line with the EFSA recommended intake [17], although lower than in the previous study (<1 year: 129 mg; 1–3 years: 229 mg) [2].

Optimal iron intake is essential for the proper development of the nervous system, and without it, dysfunction can occur [41]. In our sample, iron intake was inadequate in both age groups (EFSA recommendation 8 mg/8 mg) (Table 2). Compared with the study by Erdélyi-Sipos et al [2] (<1 year: 6 mg; 1–3 years: 7.4 mg), our results were lower. Insufficient iron intake is due to low meat consumption, including low red meat consumption [17]. Our study confirmed this, as the consumption of white meat, such as chicken, was predominant among children, while the intake of red meats was rare, which is in line with Hungarian meat consumption habits [42]. Although the main sources of calcium were milk, dairy products, and infant formula, those of iron were primarily infant formula, meat, meat products, and, to a lesser extent, cereals. Children did not consume a sufficient amount of these, which is consistent with the results of previous international studies [43].

Zinc intake in the under 1-year age group was at the lower end of the recommended range and inappropriate in the 1- to 3-year group (recommended 4 mg for both age groups) (Table 2) [17].

However, the average daily intake of potassium in our sample was above the recommended 800 mg in both age groups, but significantly lower (1378 mg at 1 year, 1950 mg at 1–3 years) than the results of the 2019 study [2].

The Hungarian dietary recommendations provide an appropriate basis for the dietary prevention of micronutrient deficiencies, which are based on the OKOSTÁNYÉR® developed by the Hungarian Dietetic Association, setting out the main principles of a balanced diet. The guideline emphasizes the role of a varied, nutrient-dense diet, with particular attention to high-quality protein sources, vegetables, fruits, whole grains, and dairy products [44,45]. For the management of specific deficiency states, such as vitamin D, iron, or calcium deficiencies, the current methodological recommendations of the Hungarian College of Health Professionals provide guidance, including the use of targeted vitamin and mineral supplementation when necessary [28]. These professional guidelines provide comprehensive guidance for the development of an age-appropriate diet, as well as for the prevention and treatment of possible deficiencies.

In 2010, a complex Hungarian nutritional survey of 1- to 3-year-old children revealed inadequate intakes of vitamins and minerals (vitamin C, D, folic acid, calcium, iron), which need to be addressed and prevented as a priority for optimal growth and development. It also emphasizes the importance of a balanced diet and recommends the incorporation of special products into the diet when necessary [46].

Proper nutrition should be emphasized in the early years of life. A feeding disorder can significantly affect daily energy and nutrient intake, which also affects children’s health and ideal development [47]. Several international studies have examined how eating disorders in early childhood affect nutrient intake. A study of children aged 1 to 5 years with picky/selective eating behaviors by Kwon et al [32] reported low energy and micronutrient intake. In comparison, energy (1155–1340 kcal) and iron (8–10 mg) intake levels were markedly higher than those reported in our own study. It is notable that our values for calcium intake were higher (404–466 mg). Similar to our own results, vegetables have been reported to be the most frequently rejected food [31]. Volger et al [33] reported insufficient energy intake (996 kcal) among children aged 2.5 to 5 years with feeding disorders, which is consistent with the results of our study. In terms of micronutrients, intake was particularly low for vitamin D (3.7 μg), calcium (429 mg), iron (7.5 mg), and zinc (5.4 mg). Compared with our data, intake levels of vitamin D and calcium were higher, but in contrast, intake levels of iron and zinc were lower. However, it should be emphasized that we looked at even younger age groups of children. The researchers also found that carbohydrate intake accounted for 32.6% of daily energy [33], which is lower than our value, and found that children who consumed high amounts of energy-dense, nutrient-poor foods had significantly lower intake levels of fruit and vegetables. Picky/selective eating behaviors adversely affected food intake, diet quality, body weight, optimal growth, and future health; as a consequence, deficiency states are especially prominent in eating and feeding disorders [32,33]. Regarding eating behavior, our results show that a large percentage of children (40%) required distraction during meals, and some were fed in a semi-sleeping state. At first, this approach may seem helpful, as it allows parents to provide their children with the necessary nutrients. Over time, however, the child may become resistant, which can lead to a worsening of the feeding disorder and, as a result, a further decrease in the amount of nutrients consumed orally. The quality of meals also deteriorates, the enjoyment of eating can decrease, and the optimal development of eating skills can be impaired.

Our results highlight the importance of adequate nutrition in early childhood, especially in cases of feeding disorders. The data obtained, however, raise further questions regarding the underlying mechanisms of the observed nutrient deficiencies and excesses. Based on the literature, it can be assumed that differences exist between children with feeding disorders and healthy children in both the composition of the gut microbiome and in hormonal regulation (eg, ghrelin, leptin). These processes can influence the regulation of hunger and satiety, as well as energy intake and expenditure [48,49].

Despite several strengths of the study, including the clinical sample and a 3-day food record on non-consecutive days, there were also limitations. The sample of the 6-month to 1-year age group was smaller (n=6) than that of the 1- to 3-year age group (n=34), which may have influenced the statistical results, as the smaller sample is more sensitive and may distort the P value. The participants voluntarily applied for outpatient care, thus the composition of the sample may differ from that of the total population in terms of socioeconomic status, parents’ education, and/or access to healthcare, which limits the generalizability of the results. Another limitation is information bias, since the documents filled in by the parents were based on self-report. The data of the present study were mainly based on maternal reports; therefore, another limitation is that paternal reports were missing from the study. The study was not registered in an international clinical trial database, which is also a limitation of the study.

Conclusions

Feeding disorders require a modern interdisciplinary approach to the investigation and treatment of eating problems in infants and young children under 3 years of age. The dietitian is part of the treatment team in the management of PFD in early childhood based on the biopsychosocial model [13,15]. Parents come to the dietitian with a concern that their child is rejecting food according to certain aspects (eg color, taste, texture), is unable to eat certain foods for various medical and developmental reasons (mobility, eating ability) reasons, or is not eating enough. The most common question that arises in PFD is whether the child’s intake is adequate in terms of quantity and quality.

The results of our study show that children with PFD under the age of 3 years were characterized by inadequate intake of nutrients in terms of quantity and quality. Results showed that intake levels of energy, fat, and certain vitamins and minerals were inadequate. The occurrence of vitamin and mineral deficiencies differed by age group: in the younger group (6 months-1 year), magnesium deficiency occurred, while in the older group (1- to 3-years), vitamin B6 and zinc deficiencies were found. All food groups, except carbohydrates and baked goods, had a lower range of acceptable foods, which can increase the risk of nutrient deficiencies and the need for supplementation.

Our research confirms that dietetic care is essential for the optimal management of PFD at the investigation, diagnosis, and treatment phases. The primary goal of working with children and families affected by feeding disorders is to ensure adequate energy and nutrient intake to support optimal growth and development. Importantly, even if treatment does not immediately lead to improvement, the child’s energy and nutrient intake must continue to be ensured throughout the course of care.

Based on our findings, it is recommended that healthcare professionals regularly monitor children’s psychosomatic development, including changes in body weight and height, as well as motor and speech development, feeding skills, and parental feeding style, and that they implement targeted intervention strategies as needed. Accordingly, the following recommendations can be formulated for healthcare professionals working with children with PFD: ongoing monitoring of psychosomatic development (particularly weight and height), motor and speech development, feeding skills, and parental feeding style. Finally, our results can serve as a practical example for planning preventive measures and contributing to the support of children’s healthy development and to the long-term improvement of their growth and nutrition.

In future research, it would be important to include a larger and more diverse sample, as well as to apply complementary data collection methods, such as objective measurement tools, such as the doubly labeled water or stable isotope methods, which may improve the accuracy of self-reported dietary data. Within the framework of the present study, the use of these methods was not possible, but in the future, we recommend their introduction. Furthermore, we plan to register our research in an international clinical trial database to promote data sharing and transparency.