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JOSS :

Journal of Social Science

PICKY EATING IN CHILDREN: ORAL MOTOR DISORDER AND DELAYED

SPEECH AS RISK FACTOR

Audi Yudhasmara

, Asrini Kaninta Adani

, Ida Narulita Dewi

, Widodo Judarwanto

Sandiaz Yudhasmara

Bunda Women and Children Hospital Jakarta, Indonesia

1,4

, Public Health Center Kebon

Jeruk Jakarta, Indonesia

, Hermina General Hospital Jakarta, Indonesia

, Ulin General

Hospital Banjarmasin, Indonesia

E-mail: [email protected]

KEYWORDS

Picky Eater, Fussy

Eater, risk factor,

characteristics, oraI

motor disorder,

deIayed speech.

ABSTRACT

Picky eating is not a diagnosis or disease, but rather an indication or a

symptom of underlying irregularities within a child's physiology. It

manifests as a refusal to consume food or drink or struggles with ingesting

appropriate types and quantities for their age, from the simple act of

opening one's mouth without coercion, to chewing, swallowing, and

digesting without any external pressure or need for specific nutrients or

medications. Numerous risk factors have been identified as significant

contributors to the presence of picky eating in children, most notably oral

motor disorders and delayed speech development. This observational

analytic study involved 138 children between the ages of 6-60 months as

subjects, with interviews conducted by their parents serving as the primary

method of data collection. Developmental Pre-screening Questionnaire

(KPSP) and modified questionnaire of risk factor of picky eating were

utilized to evaluate each child's overall development and assess potential

risk factors related to feeding difficulties. Findings from this investigation

indicated that both oral motor disorders and delayed speech had notable

effects on children aged 6-60 months residing in MaIang.

INTRODUCTION

Improving children's growth and development from an early age is a priority for

parents. Efforts in improving the quality of human resources must be made early and

continuously to prevent or detect diseases and disorders in children. Parents often face many

questions and problems in doing so. One of the problems is difficulty eating in children,

which has a direct impact on their growth and development (Goh & Jacob, 2012).

Picky eating is not a diagnosis or a disease, but rather a symptom or sign of

abnormalities and problems in the child's body. Picky eating refers to children who do not

want or refuses to eat or have difficulty eating certain type and amount of food or drink that

is appropriate for their age, starting from not opening the mouth firmly, chewing, or

swallowing to the process of digestion and absorption without the help of consumption of

certain vitamins and drugs (Judarwanto, 2009).

Early childhood is considered a golden period for brain growth and the development

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of children's thinking abilities. It is also an important period for children's brains to become

more open, educated, and enriched. However, the downside is that children are more

sensitive to the environment, especially poor nutritional intake, lack of stimulation, and

inability to access adequate health services (Ministry of Health RI, 2011). (Yusuf et al., 2008)

state that brain growth reaches 75% of adult size by the age of 5 years. Ironically, infants and

children up to the age of 5 years are vulnerable to malnutrition, including PEM (Diana et al.,

2010). This confirms that the age 0-5 group is the stage where child development needs to

be improved. Six months is the age when infants should be introduced to complementary

foods (IDAI, 2015). Therefore, six months of age is the minimum age to determine whether

a child has feeding difficulties or has risk factors (Bryant‐Waugh et al., 2010).

In the United States in 2004, 19-50% of parents complained that their children were

very picky eaters, resulting in certain nutrient deficiencies (Waugh et al., 2006). The

Gateshead Millennium Baby Study in 2006 in the UK stated that 20% of parents said their

children had eating problems, with the highest prevalence of children only wanting to eat

certain foods (Carruth et al., 2004).

Research conducted in Jakarta stated that in preschool children aged 4-6 years, the

prevalence of eating difficulties was 33.6%. 79.2% of this number has lasted more than 3

months (Judarwanto, 2008). According to the child development clinic of the Affiliated

Program for children development at George Town University, 6 types of eating difficulties

in children are only willing to eat liquid or crushed food: 27.3%, difficulty sucking, chewing,

or swallowing: 24.1%, strange and odd eating habits: 23.4%, dislikes a wide variety of foods:

11.1%, delayed self-feeding: 8.0%, mealing time tantrums: 6.1% (Judarwanto, 2009).

Based on the data, the age group with the most eating difficulties is 1-5 years old (58%),

and the largest gender is male (54%). Feeding problems were found in 50 out of 109 children

(45.9%) (Soedibyo & Mulyani, 2016). Symptoms of eating disorders in children include (1).

difficulty chewing, sucking, and swallowing food or only eat soft or liquid food, (2) vomiting

or spitting out food that enters the child's mouth, (3) eating for a long time and playing with

food, (4) there is no desire to eat or shut the mouth when being fed, (5) spilling food or

deliberately vomiting, refusing feedings from parents, (6). Disliking various foods and (7)

eating habits that are unlike those of other children (Judarwanto, 2009).

Processing food and speaking is said to use an oral motor which refers to the use and

coordination of the lips, tongue, jaw, teeth, and hard and soft palate. One of the oral motor

coordination disorders is feeding difficulties so oral motor, speech, and feeding difficulties

in children can theoretically influence each other. so eating and speaking have a close

relationship since the early stages of human development (Case-Smith et al., 2014).

Understanding this relationship is critical to identifying and addressing potential

problems in both areas. Meanwhile, there is still very few research on feeding difficulties in

children in Malang, especially regarding risk factors for feeding difficulties in children aged

6 to 60 months. Knowing the relationship between oral motor disorders, speech difficulties,

and feeding difficulties in children will be important as a first step to addressing the problem

of eating disorders and preventing eating disorders and other problems that may arise in

children (Angraini et al., 2021).

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METHOD RESEARCH

This study is an observational analytic cross-sectional study to determine the role of

oral motor disorders and speech difficulties in feeding difficulties in children aged 6-60

months in Malang City in 2018.

Malang City consists of five sub-districts and randomization was used to determine the

study areas. Of the five sub-districts, data were collected in villages under six health centers

in Malang with a large number of children aged 0-60 months. These are Dinoyo with 5952

children, Mojolangu with 3855 children, Gribig with 5473 children, Arjuno with 2627

children, Kendalkerep with 4638 children, and Kedungkandang with 4214 children. These

six health centers are also the health centers that have collaborated with Saiful Anwar

Hospital Malang.

This study was conducted in Kendalkerep, Arjuno, Dinoyo, Mojolangu,

Kedungkandang, and Gribig health centers, which managed to collect 138 child subjects with

the youngest age of 6 months and the oldest of 60 months and had an average age of 27.7

months.

The inclusion criteria in this study were all children aged 6-60 months who came as

Posyandu participants in an area of Malang City from January 2018 - February 2018. The

child's parents could read and understand Indonesian and were willing to participate in the

study with a written statement. Children with clinically diagnosed congenital abnormalities,

post-infection sequelae, and organic dysfunction were excluded from the study sample. The

study used a modified questionnaire containing several questions from the Children's Eating

Behaviour Questionnaire (CEBQ), risk factors related to the subjects and their environment,

and the KPSP recommended by the Ministry of Health to assess the development of toddlers

by interview. Data were processed using the SPSS 11 program with a significant level or

probability value of 0.1 (p = 0.1) and a 90% confidence level (ɑ = 0.1). The analysis used

was bivariate analysis or examining the relationship between the dependent and independent

variables using the chi-square test (Hall & Cohn, 1986).

RESULTS AND DISCUSSION

Description of Respondent Characteristics

Table 1

Respondent Characteristics

No.

Characteristics

Category

Mean

Child's age (month)

27.7

13.3

Gender of the child

Male

40.9%

Female

59.1%

Nutritional status

Undernourished

13.1%

Good nutrition

118

86.1%

Over nutrition

0.7%

Exclusive

breastfeeding

7.3%

Yes

127

92.7%

Father's Education

Elementary

19.7%

High

110

80.3%

Father's occupation

Working

137

100.0%

Not working

0.0%

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Father's Income

Low

19.7%

Medium

54.0%

High

26.3%

Mother's Education

Low

15.3%

High

116

84.7%

Mother's Occupation

Working

67.2%

Not working

32.8%

Mother's Income

Low

106

77.4%

Medium

17.5%

High

5.1%

Ethnicity/race

Non-Javanese

9.5%

Javanese

124

90.5%

Socio-economics

Low

31.4%

Medium

46.7%

High

21.9%

Based on the data from the sample collection, the gender proportion has quite different

numbers, namely 56 children, or 40.9 percent male, and 81 children, or 59.1 percent female.

Description of nutritional status obtained 18 people or 13.1 percent had a nutritional status less,

1 person, or 0.7 percent had a nutritional status more, and 118 people, or 86.1 percent had a

good nutritional status. From the sample collection, it was also obtained that children under

five who did not receive exclusive breastfeeding were 10 children or 7.3 percent and were

given exclusive breastfeeding and 127 children or 92.7 percent.

The description of ethnicity/race obtained 13 people or 9.5 percent were of non-Javanese

origin 124 people or 90.5 percent were of Javanese origin and were cared for by their mother

and father, 102 people, or 74.5 percent, 31 people, or 22.6 percent were cared for by

grandparents, and 4 people or 2.9 percent used caregivers.

Data regarding parental education obtained the education level of 27 fathers or 19.7

percent with elementary education and 110 or 80.3 percent with higher education. Equipped

with 137 fathers or 100.0 percent working and 0 fathers or 0.0 percent not working Description

of fathers' income is dominated by fathers with moderate income as much as 54.0 percent, then

27 people or 19.7 percent with low income, and 36 people or 26.3 percent with high income.

Data regarding the child's mother showed that the mother's education level was low at 21 people

or 15.3 percent and 116 people or 84.7 percent with high education. Mothers who have jobs

are found to be 92 people or 67.2 percent and 45 people or 32.8 percent do not work. The

income of the child's mother obtained data with 106 people or 77.4 percent with low income,

24 people, or 17.5 percent with moderate income, and 7 people, or 5.1 percent with high

income. Socio-economic description obtained 43 people or 31.4 percent have a low category,

64 people or 46.7 percent have a medium category, and 30 people, or 21.9 percent have a high

category.

Table 2

Basic characteristics of study subjects and feeding difficulties in children

Variable

Gender

Male

40,6%

Female

59.4%

Nutritional status

Less

15,6%

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Good

84,4%

Over

0,0%

Exclusive

breastfeeding

15,6%

Yes

84,4%

Yes

91,7%

Father's education

Elementary

3,1%

High

96,9%

Father's

Occupation

Work

100%

Father's Income

Low

18,8%

Medium

53,1%

High

28,1%

Mother's

Education

Low

9,4%

High

90,6%

Mother's

Occupation

Not working

53,1%

Medium

21,9%

High

9,4%

Mother's Income

Low

68,8%

Medium

21,9%

High

9,4%

Ethnicity/Race

Non-Javanese

12,5%

Javanese

87,5%

Socio-economics

Low

28,1%

Medium

43,8%

High

28,1%

From the samples obtained, the characteristics of children with eating difficulties were

dominated by the female gender, namely 19 children (59.4%) than the male gender of 13

children (40.6%). Nutritional status in children with difficulty eating was found to be the

highest number in children with good nutritional status 27 children (84.4%) then in

undernourished children, five children (15.6%), and no children with more nutritional status

were found. Children with difficulty eating in this study were found in children with exclusive

breastfeeding, namely 27 children (84.4%) while children who were not exclusively breastfed

were five children (15.6%).

The father's educational status was found to be one person classified as low education

(18.8%), 31 people (96.9%) with a total of 32 working fathers (100%). Father's income

classified as low was found to be 6 people (18.8%), medium income 17 people (53.1%), and

high income 9 people (28.1%). The educational status of the mothers was found to be 3 people

with low education (9.4%), 29 people with high education (90.6%) with mothers who did not

work 17 people (53.1%), and mothers who worked 15 people (46.9%). Low mother income

was 22 people (68.8%), medium income was 7 people (21.9%), and high income was 3 people

(9.4%).

The characteristics of ethnicity and race in children with eating difficulties were found

to be children with tribes outside Java in the amount of 4 children (12.5%) and 28 children of

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Javanese ethnicity (87.5%). The low socioeconomic level of the family was found to be nine

children (28.1%), a moderate or middle level of 14 children (43.8%), and a high socioeconomic

level of 9 children (28.1%).

Table 3

Relationship between risk factors and feeding difficulties in children

No.

Risk Factors

Difficulty Eating

Total

Chi-square Test

Yes

Description

Oral

Motor

Disorder

8.0%

57.7%

65.7%

0.000

Significant

Speech

Disorder

12.4%

70.1%

113

82.5%

0.000

Significant

Yes

10.9%

6.6%

17.5%

The results of bivariate analysis found that oral motor disorders and speech disorders

were significant risk factors. Cross tabulation between oral motor impairment and feeding

difficulties showed that infants with feeding difficulties were divided into 11 children without

oral motor impairment and 21 children with oral motor impairment. Then, from children who

did not have feeding difficulties, 79 children did not have oral motor disorders and 26 children

had oral motor disorders. The results of the chi-square test showed that there was a significant

relationship between oral motor impairment factors and feeding difficulties in children (p <

0.05).

Cross tabulation between speech impairment and eating difficulties obtained the results

that children who experience eating difficulties are divided into 17 children who do not have

speech disorders and 15 children who have speech disorders, then children who do not

experience eating difficulties are divided into 96 children who do not have speech disorders

and 9 children have speech disorders. The results of the chi-square test show that there is a

significant relationship between the factor of speech disorders and eating difficulties in children

(p < 0.05).

DISCUSSION

Based on the results of the study, the characteristics of the study subjects were that girls

at the age of 6-60 months experience more eating difficulties than boys of that age. This is

inversely proportional to research conducted by (Soedibyo & Mulyani, 2016) where children

with male gender were 54% compared to women at 46%. Also, the age group that experienced

the most eating difficulties in children was at the age of 12-60 months.

The study found that 84.4% of children with eating difficulties were well-nourished

children. This is by research conducted by Dian in Bandar Lampung where no significant

relationship was found between the behavior of difficult eating in children and the nutritional

status of children, especially in pre-school children. Another study conducted by (Van der

Horst, 2012), in children 12-48 months found that children with feeding difficulties tend to

weight the average age or underweight compared to children who do not have feeding

difficulties (Judarwanto, 2008).

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In this study, it was found that children with feeding difficulties were dominant in

children with exclusive breastfeeding. This is inversely proportional to a cohort study

conducted by Specht in 2018 in Europe that children who were breastfed until 4-5 months of

age were more likely to have no problems with feeding difficulties in children than children

who were breastfed until only 0-1 month of age regardless of the mother's education level.

However, this study is in line with research conducted by Fitria Wahyu on preschool children

in Pasuruan that there is no relationship between exclusive breastfeeding history and the

occurrence of difficulty eating in children, especially preschool children (Specht et al., 2018).

The education of fathers and mothers who have children with difficulty eating is

dominantly a high level of education ranging from high school to college. This is in line with

Fitryanti's research in 2018 which concluded that there is no relationship between parents'

education level and eating difficulties in children. Meanwhile, in research conducted by

(Steinsbekk et al., 2017) in Norway, the parenting role is an important factor that can reduce

the risk of children having difficulty eating. It can be assumed that the level of education of

parents does not guarantee that parents can have good or appropriate parenting to children. The

income level and socioeconomic level of parents of children with eating difficulties in this

study were dominated by fathers who worked with moderate income, mothers who did not

work, and families with moderate or middle socioeconomic levels. In a study conducted by

Riyadi in 2011, it was said that there was a relationship between parental employment and

family socioeconomic level with eating difficulties in children. It was also stated by the

Ministry of Social Affairs of the Republic of Indonesia in 2012 that families with high

socioeconomic levels will have easier access to food diversity that can shape certain eating

patterns (Riyadi et al., 2011).

In the risk factors studied, there was a significant association between oral motor disorders

and speech disorders in children with feeding difficulties in children. Based on other studies,

picky eaters tend to have oral motor disorders (Carruth et al., 1998). This is due to the child's

inability to chew or process food with a certain texture (Sabilah et al., 2016). Oral motor

disorders can be included in eating process disorders, starting from inserting food in the mouth,

chewing, and swallowing. Skills and coordination abilities of gross motor movements around

the mouth play a role in the eating process. Motor movements in the form of coordination of

biting, chewing, and swallowing movements are carried out by muscles in the upper and lower

jaw, lips, tongue, and many other muscles around the mouth. Disorders of the eating process

in the mouth called oral motor disorders are often in the form of chewing disorders. This is

why children can only drink milk and cannot eat other types of food (Judarwanto, 2009). Other

research suggests that children with eating aversions or picky eaters choose foods because of

their difficulty in chewing foods such as meat and vegetables. This may lead to speech delay

(Chatoor et al., 2000). Adams-Chapman stated in her research that children who have a history

of difficulty eating at the age of 18-22 months tend to experience speech and language delays.

This is also corroborated by Putnick where difficulty eating in children can be an indicator of

growth and development problems including speech and language skills (Adams-Chapman et

al., 2013).

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CONCLUSION

This study shows that there are dominant characteristics in children with feeding

difficulties at the age of 6-60 months. Speech disorders and oral motor disorders in children

can be a risk factor in the occurrence of feeding difficulties in children. Considering that oral

motor disorders are one of the main risk factors for eating difficulties in children, it is necessary

to conduct long-term prospective studies, especially in observing more risk factors and early

intervention on these various risk factors to optimize children's eating ability. Considering that

the growth and development of children are influenced by food intake, it is very important to

conduct further research on the possibility of other risk factors for eating difficulties in children

as a step to add to the repertoire of science.

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Audi Yudhasmara

, Asrini Kaninta Adani

, Ida Narulita Dewi

, Widodo

Judarwanto

, Sandiaz Yudhasmara

(2023)

First publication right:

JoSS - Journal of Social Science

This article is licensed under a Creative Commons Attribution-ShareAlike 4.0

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