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Sensory processing and child appetitive traits: findings from the ROLO longitudinal birth cohort study

Nutrition Journal volume 23, Article number: 136 (2024) Cite this article

Abstract

Background

Oral sensory hypersensitivity has been linked with fussy eating predominantly in non-typically developing children. We hypothesized that child ‘Oral’ (touch, smell and taste in the mouth) and ‘Social-Emotional’ (response to social expectations) sensory processing are associated with child appetitive traits in typically developing preteen children. Additionally, we explored relationships between maternal sensory profiles and their offspring’s sensory profile.

Methods

This is secondary analysis of 130 mother-child dyads from the 9–11-year-old follow-up of the ROLO longitudinal birth cohort study. The Dunn Sensory Profile (Adolescent/Adult) and the Dunn Child Sensory Profile 2 were used to assess maternal and child sensory profiles, respectively. The Children’s Eating Behaviour Questionnaire was used to assess child appetitive traits. Multiple linear regression examined associations between ‘Oral’ and ‘Social-Emotional’ segments of the child sensory profile and child appetitive traits. Associations between maternal and child sensory profiles were examined using sensory profile quadrants (Dunn’s sensory processing framework). These refer to four distinct patterns of sensory processing that indicate how an individual responds to sensory input.

Results

In total, 130 mother-child dyads were included. In adjusted analysis child ‘Oral’ sensory processing was associated with higher mean scores in the appetitive traits ‘Desire to Drink’ (B = 0.044, 95% CI = 0.025,0.062) and ‘Food Fussiness’ (B = 0.080, 95% CI = 0.059,0.101) and with lower mean scores in ‘Enjoyment of Food’ (B=-0.038, 95% CI -0.055,-0.022). Child ‘Social-Emotional’ responses were associated with higher mean scores in ‘Desire to Drink’ and ‘Food Fussiness’. Higher scores in the maternal sensory profile quadrants of ‘Sensitivity’, ‘Avoiding’ and ‘Registration’ were positively associated with higher scores in the corresponding child sensory profile quadrants.

Conclusion

Our findings suggest that in typically developing children presenting with fussy eating, oral sensory hypersensitivity and higher scores in social-emotional responses to sensory processing may be an underlying determinant. The relationship observed between ‘Oral’ and ‘Social-Emotional’ sensory processing segments and ‘Desire to Drink’ requires further research to ascertain the type of drinks being consumed and how this impacts appetite. Further research is also required to explore the influence of maternal sensory profile on their offsprings response to sensory input.

Peer Review reports

Background

Feeding is a sensorimotor skill that evolves during the first years of life. It is a highly complex process and is dependent on learning from experience and neurological maturation. Sensory processing is the ability to process and interpret information from our senses (e.g. vision, touch, taste, body position, hearing). As humans we are surrounded by the sensory events of daily life. Individuals vary in the degree to which they are sensitive to sensory stimuli and how much they enjoy or react to different sensory experiences [1]. How we notice, recognize, interpret and respond to various stimuli determines an individual’s sensory profile. The Dunn [2] sensory processing framework proposes four basic patterns of sensory processing based on an individual’s neurological threshold for detecting and responding to sensory stimuli. These include; ‘Seeking’ which measures the degree of which an individual will seek sensory input, ‘Avoiding’ which measures how much an individual is bothered by sensory input, ‘Sensitivity’ measures an individual’s ability to detect or notice sensation and ‘Registration’ measures the degree to which an individual misses sensory input [2, 3].

The ‘Oral’ sensory processing segment of the Child Sensory Profile 2 (CSP2) measures a child’s response to touch, smell and taste in the mouth [3]. Heightened reaction to smell, touch and taste has been shown to be related to food acceptance, food refusal and food fussiness [4, 5]. In general, when compared with typically developing children, children with autism spectrum disorder (ASD) have been reported to present with heightened levels of oral hypersensitivity [6,7,8] and higher levels of feeding difficulties [9, 10]. In the typically developing child, fewer studies have examined the impact of oral sensory processing on a range of appetitive traits (dispositions towards foods that differ between individuals [11]).

Fussy eating has been defined as the consumption of a limited variety or quantity of foods through the rejection of a significant amount of familiar and unfamiliar foods [12, 13]. Poor diet quality [14] and anxiety and stress for the family and child [15] are some of the implications of food fussiness. Identifying the underlying factors driving fussy eating behaviors could help direct strategies to address and manage it. Issues with the perceived sensory properties of food may be an underlying factor for rejecting food in both typically and atypically developing children [1, 16]. As foods differ in their sensory properties, the integration of most of the senses are involved in eating. Research has shown that children with aversive reactions to textures, smells and temperature of food show high levels of food fussiness and reluctance to try new foods [17,18,19]. A recent study of 589 Spanish children aged 3–7 years old observed that taste and smell sensory reactivity was significantly correlated with food selectivity [20]. Refusal to eat fruit and vegetables, and/or unfamiliar foods in childhood has been associated with increased levels of taste, touch and smell sensitivity [21], however, other determinants such as lack of exposure, cultural or parental feeding practices have also been shown to be influential [22, 23].

Appetitive traits are related to both diet quality and child weight status [24,25,26]. The preteen years are a crucial period for consolidating eating behaviours developed in the early years [14, 27, 28]. Within these years children are developing autonomy in their eating habits, and are often eating outside the home. Prolonged sub-optimal eating habits can significantly impact growth, nutritional status and cognitive development [13, 29,30,31]. Research has shown that diet quality decreases as age increases [14], therefore it is vital to address barriers to healthy eating habits before they become entrenched.

Twin studies have shown that appetitive traits are developed by a combination of genetics and environmental factors [32, 33], albeit the influence of each differ as per behavior. A twin study of children aged 3.5 years old indicated that food fussiness and fruit and vegetable liking shared common genetic factors [33]. Sensory sensitivity is believed to be an inherent characteristic [34].

Research on the influence of maternal sensory profile on their offspring’s sensory profile is lacking. Few studies have examined if a relationship exists between maternal and child sensory processing patterns and how this may relate to their offspring’s eating behaviors. Research suggests that maternal eating behavior is associated with child eating behavior [35, 36], and that children often imitate the attitudes and behavior of their parents, particularly their mothers [37]. Awareness of how maternal sensory processing patterns influence their offspring’s sensory processing patterns may help provide better understanding of their behaviors.

Food avoidant appetitive traits such as fussy eating have been linked with anxiety and low mood [38, 39] and to higher levels of parent reported negative affect in children [40]. Child temperament has been recognized as a significant factor in how a child behaves in the feeding environment [41]. The ‘Social-Emotional’ responses associated with sensory processing segment of the CSP2 measures a child’s expressiveness in a social situation [3] and includes items about self-esteem, emotions and fears. To date, research has not explored the relationship between child ‘Oral’ hypersensitivity and ’Social-Emotional’ responses associated with sensory processing, and how this relates to appetitive traits. Cross sectional and longitudinal studies have observed a link between childhood fussy eating and the child with a predisposition to get upset or distressed easily (the emotional temperament) [42,43,44]. Zucker, Copeland [39] observed that food fussiness was associated with current and future psychopathological symptoms (anxiety, depression, attention-deficit disorder). A deeper understanding of the relationship between fussy eating and heightened ‘social-emotional’ sensory processing argues for the value of early identification of predictors of fussy eating, and how this may help when planning interventional strategies.

In the current study, we describe the sensory profiles of a cohort of healthy mother-child pairs. Our primary aim explored the relationship between child ‘Oral’ sensory processing and child appetitive traits at 9–11 years old in typically developing children. A secondary aim explored associations between child ‘Social-Emotional’ responses associated with sensory processing and child appetitive traits. Lastly, we explored relationships between maternal and child sensory profile quadrants as per the Dunn’s Sensory Processing Framework [2].

Methods

Study population

This is secondary cross-sectional analysis of 130 mother-child pairs from the ROLO (Randomized controlled trial of a low glycemic index diet) longitudinal birth cohort study. The primary study took place in the National Maternity Hospital, Dublin, Ireland from 2007 to 2011, where 800 women who were on their second pregnancy, and had previously given birth to an infant weighing over 4 kg (macrosomia) were recruited. Detailed methods and results of the primary study have been published elsewhere [45]. Women and their second born child (n = 759) have been followed up at 3 and 6 months, 2 years, 5 years and at 9–11 years (Preteen study) as part of the ROLO longitudinal birth cohort study. Data for the current study is from the 9–11-year-old (Preteen study) follow-up. Mother-child pairs were invited to attend a study day when their child turned 9 years old. In all, 432 mother-child pairs participated. Of the 432 ROLO Preteen follow-up participants, 132 completed maternal and child sensory profiles and the Children’s Eating Behaviour Questionaries. Two children had a diagnosis of ASD and were therefore excluded, leaving a study cohort of 130 participants.

Ethical Approval

Ethical approval for the 9 to 11-year follow-up study was granted by University College Dublin (UCD) Research Ethics Committee (LS-15-06-Geraghty-McAuliffe). Details on retention strategies implemented to maintain study engagement in the ROLO cohort were published previously [46].

Maternal baseline data, early child feeding and general health of children at 9–11 years old

Baseline maternal data were collected during pregnancy on maternal age at delivery, education level and ethnicity. Women choose between six categories ranging from no schooling to third level or above education. Maternal ethnicity was dichotomized into white Irish or other.

Breastfeeding exposure and duration were recorded at 6 months, 2 years and 5 years. At each of these timepoints, mothers reported if they had ‘breastfed ever’ and the duration (weeks) that they had breastfed for. As a marker of any breastfeeding exposure, a composite variable was created to categorize participants into ‘breastfed ever’ or ‘never breastfed’. At the 2 year and 5-year follow-up mothers reported the age (weeks) their infant had commenced complimentary feeding. This data was dichotomized into whether the child had started complimentary feeding as per European [47] and national [48] recommendations or not, that is that complementary foods are not introduced before four months (17 weeks), but should not be delayed beyond six months (26 weeks). Lifestyle questionnaires were completed by mothers about the general health of their child during the 9–11-year-old follow-up study. History of ASD, sensory processing disorder, ADHD or any other physical or developmental diagnoses were recorded.

Maternal and child anthropometry at 9–11-year follow-up

All measurements were obtained and calculated by a trained researcher. At the 9–11-year-old visits, maternal and child weight were measured using a calibrated stand-on digital weighing scale (SECA 813 GmbH & co. Kg. Hamburg, Germany ) to the nearest 0.1 kg. Participants were measured in light clothing without shoes. Mothers and child’s standing height was measured, without shoes, with head aligned in the Frankfort plain, using a free-standing stadiometer (SECA 217 GmbH & co. Kg. Hamburg, Germany) and measurements were recorded to the nearest 0.1 cm. Body mass index (BMI) was calculated for mother and child as kilogram per square meter (kg/m2). Maternal BMI was classified as per the World Health Organization classification system [49]. Children’s BMI scores were converted to standardized z-scores according to the 1990 UK age-and sex-specific reference data using Excel LMS Growth macro [50]. BMI z-scores were categorized using the World Health Organization criteria for children aged 5 to 19 years [51].

Exposure: Sensory Profiles

The Dunn 60-item Adolescent/Adult Sensory Profile (A/ASP) [52] was used to assess maternal sensory profiles and the Dunn 86-item Child Sensory Profile 2 (CSP2) caregivers questionnaire (for children aged 3–14 years old) was used to assess child sensory profiles [3]. The A/ASP Sensory Profile and the CSP2 evaluate an individual’s behavioral responses to everyday sensory experiences. Scores are generated to provide an individualized profile of sensory processing across four quadrants. The Dunn four quadrant model of sensory processing is based on two domains; neurological threshold and behavioral response. The neurological construct refers to the threshold of an individual’s response to sensory stimuli and can range from low to high. The second construct, behavioral response, is based on whether an individual has a passive or active strategy in how they respond to their environment. These two constructs cross to form four major sections. The four quadrants are similar in the A/ASP and the CSP2 albeit with minor variations in their titles and differences in the statements within the profiles. The quadrants are (CSP2); Sensory Seeking (Seeking/Seeker) – a high score indicates the individual craves high amounts of environmental stimuli (e.g. craves certain foods, tastes or smells’) (CSP2 oral section), Sensation Avoiding (Avoid/Avoider) - a high score indicates avoidance of high levels of stimuli and being upset by high sensory input (e.g. I move away when others get too close to me’) (A/ASP Touch section); Sensory Sensitivity (Sensitivity/Sensor) – high scores indicate those who are sensitive to stimuli and quickly detect it in their environments (e.g. ‘limits self to certain food textures’) (CSP2 Oral section) and Low Registration (Registration/Bystander) individuals with high scores typically miss more sensory input than others (e.g. I don’t smell things that other people smell’) (A/ASP Taste/Smell section). Quadrant scores are calculated from the raw scores obtained from the statements within the sensory profiles via a 5-point Likert scale ranging from 1 to 5 (1 (Almost Never) to 5 (Almost Always). The A/ASP raw scores are derived from six sensory processing subscales; taste/smell, movement, visual, touch, activity level and auditory processing. The CSP2 raw scores are derived from nine sensory processing subscales; auditory, visual, touch, movement, body position, oral sensory processing and three subscales that reflect emotional and behavioral responses that might indicate a child’s sensory processing abilities; conduct, social-emotional responses (items indicate the child’s psychosocial coping strategies) and attentional responses associated with sensory processing. Quadrant scores are placed on pattern grids that visually represent how the individual’s sensory processing is compared to that of other adolescents/adults or children.

The CSP2 was completed by the child’s mother to evaluate the child’s behavioral response to everyday sensory experiences. The two CSP2 subscales used as predictors of appetitive traits were ‘Oral’ sensory processing’ and ‘Social-Emotional’ responses associated with sensory processing. The ‘Oral’ sensory processing segment (10 items) measures the child’s response to touch, smell and taste in the mouth (e.g. gags easily from certain food textures or food utensils in the mouth). The ‘Social-Emotional’ responses associated with sensory processing segment (14 items) measures the child’s expressiveness in a social situation (e.g. Is sensitive to criticisms).

Mothers were posted the adult and child sensory profiles with instructions provided on how to complete both profiles. Completed profiles were returned either at in-person study visits or by post using the stamped addressed envelope provided. Participants were instructed to answer questions regarding how they generally respond to sensations, as opposed to at that specific time. Instructions were provided to complete the questionaries reflecting pre-COVID-19 sensory status. The adult and child sensory profiles have good internal and external validity [34]. During development the internal consistency (Cronbach alpha) method was used to estimate the reliability of the A/ASP and the CSP2. For our cohort, Cronbach alpha for the A/ASP quadrants ranged from 0.70 to 0.78. The Cronbach alpha for CSP2 quadrants ranged from 0.840 to 0.941 and for the oral sensory processing and social-emotional processing segments were 0.884 and 0.941 respectively.

Outcome: Child appetitive traits

The Children’s Eating Behaviour Questionnaire (CEBQ) [53] was completed by mothers to evaluate their child’s appetitive traits. This is a 35-item psychometric tool, which was designed to assess appetitive traits in children. The CEBQ has been shown to have good internal and external reliability [54, 55] and has been validated against observational measures of eating behavior, corresponding well to children’s energy intake [54]. Each item response is graded on a 5-point Likert scale (‘never to always’) with 5 items within the CEBQ being reverse scored, due to negative phrasing. Each question relates to one of eight eating styles which can be classed as either ‘Food approach’ or ‘Food avoidant’. The food approach category includes ‘Food Responsiveness’, ‘Enjoyment of Food’, ‘Emotional Overeating’ and ‘Desire to Drink’. The ‘Food Responsiveness’ subscale contains five questions which assess a child’s appetite and whether they display a heightened response to external food cues. The ‘Enjoyment of Food’ subscale consists of four questions assessing a child’s enjoyment and interest in food. The ‘Emotional Overeating’ subscale contains four questions, which explore overeating as a reaction to negative emotions such as annoyance, worry, anxiety or boredom. The ‘Desire to Drink’ subscale contains three questions assessing an increased desire for frequent beverage consumption. The ‘Food avoidant’ category includes ‘Satiety Responsiveness’, 'Slowness Eating’, ‘Emotional Undereating’ and ‘Food Fussiness’. The ‘Satiety Responsiveness’ subscale consists of five questions, exploring a child’s inability to respond to internal satiety cues and reduction in intake due to perceived fullness. ‘Slowness Eating’ comprises of four questions pertaining to the length of time a child takes to finish their meal, indicating a lack of interest in eating. ‘Emotional Undereating’ is assessed by four questions, exploring a child’s inclination to limit food intake in times of negative and positive emotions, such as being upset, sad, happy or tired. The ‘Food Fussiness’ subscale includes six questions that assess food avoidance, selectivity and a lack of interest in food. Each subscale is summed to give a total score and this is divided by the number of items within the subscale to give a mean score of the sum. A higher score indicates the child is more likely to express this eating behavior. In the current sample Cronbach’s alpha for the CEBQ ranged from 0.699 to 0.917, thus all questions were included in the analysis.

Statistical analysis

Continuous data were tested for normality using the Kolmogorov–Smirnov test and visual inspection of histograms. Normally distributed variables were reported as mean and standard deviation (SD). Non-parametric variables were reported as median and interquartile range (IQR 25th -75th ). Categorical variables were reported as n (%). Appetitive trait variables were normally distributed and parametric tests were used. Cronbach α was performed on each subscale of the CEBQ, A/ASP and the CSP2 to assess the internal consistency of each in our cohort. As part of our descriptive analysis, child characteristics, child sensory profile scores and child appetitive traits were examined across child sex using Independent sample t-tests for normally distributed variables or Mann Whitney U tests for non-normally distributed variables. Spearman’s correlations explored relationships between child ‘Oral’ and ‘Social-Emotional’  sensory profile segments and child appetitive traits. Spearman’s correlations explored relationships between maternal and child sensory processing quadrants. In both cases, where a moderate to strong correlation was observed, further analysis was conducted using linear regression. Adjusted and non-adjusted linear regression examined associations between child ‘Oral’ and child ‘Social-Emotional’ sensory profile segments (predictors) and child appetitive traits (dependent variables). Prior to regression analysis, normality, homoscedasticity, and linearity were assessed. A forced entry approach was used for the addition of confounders to multiple regression models. Potential confounders were decided upon a priori based on the literature and on author consensus. These included child age, child sex, breastfeeding exposure, whether the child met timing recommendations for the introduction of complementary feeding or not, maternal education level, original RCT group, maternal and child BMI at the 9–11-year follow-up. To address similarity in one item contained in the child ‘Oral’ sensory processing segment (‘rejects certain tastes or food smells that are typically part of children’s diets’) and two items in the CEBQ ‘Food Fussiness’ domain (‘My child enjoys tasting new foods’ (reverse scored) and ‘My child enjoys a wide variety of food’ reverse scored), post hoc sensitivity analysis was carried out by excluding the overlapping content in the sensory profile. This yielded similar associations to previous analyses. In the multiple linear regression analysis examining associations between maternal and child sensory processing quadrants, maternal education was not included as a confounder in the regression models. To account for multiple testing, the Benjamini-Hochberg correction method was applied with a false discovery rate of 0.05. In total, 54 comparisons were completed within the analyses. This research was exploratory in design; thus, power and sample size calculations were not included for this secondary analysis. Statistical analyses were completed using IBM Statistical Package for Social Sciences (SPSS) for Windows, version 27.0. Armonk, NY: IBM, Corp.

Results

Maternal and child characteristics

General characteristics of the cohort (n = 130) are presented in Table 1. In the full cohort (n = 132), two children had a diagnosis of ASD and no children had a diagnosis of ADHD or a Sensory Processing Disorder. Our analysis excludes the two children with ASD.

Maternal sensory profiles

The majority of mothers fell within the ‘similar to others’ range for each of the sensory profile quadrants (Additional file 1). Median raw scores (25th -75th) for maternal sensory profile quadrants are presented in Table 1.

Child sensory profiles and child appetitive traits

The majority of children fell within the ‘similar to others’ range for each of the four sensory profile quadrants (Additional file 2). For the ‘Oral’ sensory processing segment, 13.8% of children had scores of ‘more than’ or ‘much more than others’. Within the ‘Social-Emotional’ sensory processing segment, 16.9% of children scored as ‘more than’ or ‘much more than others’ (Additional file 3). Median (25th -75th ) and mean (SD) scores for child sensory quadrants and sensory profile scores are presented in Table 1. The mean (SD) of the sum of each CEBQ subscale are presented in Table 1. In this cohort, 35% (n = 45) of children had a total score (sum of mean) of 4 or more in the CEBQ ‘Food Fussiness’ subscale, indicating that they either ‘often’ or ‘always’ expressed an issue with food acceptance.

Table 1 Descriptives of maternal and child characteristics from the ROLO 9–11-year follow-up
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Differences in child characteristics, sensory processing and appetitive traits across sex

Following adjustment for multiple testing, boys had higher mean (SD) BMI z-score than girls (0.5 (1.2) vs. 0.1 (1.1)) (Table 2). Boys had higher mean (SD) scores for ‘Emotional Overeating’ (2.1 (0.6) vs. 1.9 (0.5)) than girls (Table 2). Girls had higher mean (SD) scores for ‘Satiety Responsiveness’ (2.9 (0.7) vs. 2.6 (0.7) compared to boys. Boys had higher median (25th -75th ) scores in the ‘Sensitivity/Sensor’ quadrant (29.0 (24.0,36.0) vs. 25.0 (21.0,31.8)) compared to girls (Table 2).

Table 2 Differences in child characteristics, appetitive traits and segments of child sensory profile across sex
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Correlations between child ‘Oral’ and ‘Social-Emotional’ sensory processing segments and child appetitive traits

Results are presented in Additional file 4. Following correction for multiple testing a positive relationship was observed between child ‘Oral’ sensory processing and ‘Desire to Drink’ (r = 0.44), ‘Satiety Responsiveness’ (r = 0.24) and ‘Food Fussiness’ (r = 0.53). A negative relationship was observed between child ‘Oral’ sensory processing and ‘Enjoyment of Food’ (r = -0.32). A positive relationship was observed between the ‘Social-Emotional’ sensory processing segment and ‘Food Responsiveness’ (r = 0.23), ‘Emotional Overeating’ (r = 0.28), ‘Desire to Drink’ (r = 0.44), ‘Emotional Undereating’ (r = 0.24) and Food Fussiness (r = 0.29). Child ‘Oral’ and ‘Social-Emotional’ sensory profile segments were strongly correlated (r = 0.49) (Additional file 5).

Multiple linear regression - child ‘Oral’ sensory processing and child appetitive traits

In adjusted analysis, and following correction for multiple testing, a positive association was observed between child ‘Oral’ sensory processing and ‘Desire to Drink’ (B = 0.044, 95% CI = 0.025,0.062) and ‘Food Fussiness’ (B = 0.080, 95% CI = 0.059,0.101). ‘Oral’ sensory processing accounted for 35% of the variance of ‘Food Fussiness’ explained by the model. A negative association was observed between child ‘Oral’ sensory processing and ‘Enjoyment of Food’ (B =-0.038, 95% CI = -0.055,-0.022).

Multiple linear regression- child ‘Social-Emotional’ sensory processing segment and child appetitive traits

In adjusted analysis ‘Social-Emotional’ responses associated with sensory processing were positively associated with ‘Desire to Drink’ (B = 0.023, 95% CI = 0.008,0.038), ‘Emotional Undereating’ (B = 0.018, 95% CI 0.004,0.031) and ‘Food Fussiness’ (B = 0.029, 95% CI = 0.009,0.049). Adjusted and unadjusted results are presented in Table 3.

Table 3 Associations between child ‘Oral’ and child ‘Social-Emotional’ sensory processing segments of the CSP2 and child appetitive traits at 9–11 years old (n = 130)
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Correlation and multiple linear regression between maternal and child sensory profile quadrants

Examining relationships between maternal and child sensory profile quadrants, a positive relationship was observed between maternal ‘Sensory Sensitivity’ and child ‘Sensitivity/Sensor’ (r = 0.34), maternal ‘Sensation Avoiding’ and child ‘Avoiding/Avoider (r = 0.38) and maternal ‘Low Registration’ and child ‘Registration/Bystander’ (r = 0.47) (Additional file 6). In adjusted linear regression, a positive association was observed between maternal ‘Sensory Sensitivity’ and child ‘Sensitivity/Sensor’ (B = 0.345, CI = 0.133,0.574), maternal ‘Sensation Avoiding’ and child ‘Avoiding/Avoider’ (B = 0.550, CI = 0.285,0.814) and maternal ‘Low Registration’ and child ‘Registration/Bystander’ (B = 0.470, CI = 0.227,0.712) (Table 4).

Table 4 Associations between maternal and child sensory profile quadrants (n = 130)
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Discussion

Our results support our hypothesis that a child’s reaction or tolerance of oral sensory stimuli is related to child appetitive traits, specifically higher mean scores in ‘Food Fussiness’ and ‘Desire to Drink’ and lower mean scores in ‘Enjoyment of Food’. We observed positive associations between ‘Social-Emotional’ responses associated with sensory processing and ‘Desire to Drink’, ‘Emotional Undereating’ and ‘Food Fussiness’. We also observed that maternal and child sensory profiles were positively associated in three out of four sensory profile quadrants.

Child ‘Oral’ sensory processing was positively associated with ‘Food Fussiness’ even after adjusting for potential confounders. Statements within the construct of the ‘Oral’ sensory processing segment include ‘rejects certain tastes or food smells’, and ‘gags easily from certain food textures’ indicate the crossover between sensory factors, such as smell, texture, color, and temperature and how they can relate to food refusal. A previous cross-sectional study of 73 children aged 2–5 years old, investigated associations between child oral sensory sensitivity and fruit and vegetable consumption. Results showed that children who were sensitive to taste/smell stimuli ate fewer fruit and vegetables, regardless of the influence of maternal intake [21]. Previous research has also shown that maternal fruit and vegetable intake is highly correlated their child’s intake [21, 56]. However, for children with oral sensory hypersensitivity, this heightened response to oral stimuli may negate the maternal modelling role due to strength of its impact, particularly with more challenging textures, smells or tastes. Our findings highlight the importance of considering oral sensory hypersensitivity in the typically developing older child that presents with persistent food fussiness.

Our results showed a negative association between child ‘Oral’ sensory processing and ‘Enjoyment of Food’. Among the numerous factors that contribute to eating and drinking, pleasure plays a key role. Food choices are driven by the positive neurological feedback that a food taste or texture provides [57]. This may be particularly relevant to children as other determining factors for food choice, such as the nutritional benefits of the food, or the importance of meeting dietary requirements will not be priorities [58]. Based on theoretical models addressing the determinants of food choice decision making, Marty, Chambaron [59] identified three main dimensions of pleasure derived from eating that are learned during childhood. These include, the sensory dimension of eating, which relates to the pleasure experienced before and after consuming food; the interpersonal dimension, which includes the social context of eating and the psychological dimension of eating, which relates to the cognitive pleasure of eating. In the optimal environment where healthy food choices are available and there is positive parental modelling, addressing sensory issues and therefore promoting a positive relationship with food may offer a strategy to avert or tackle fussy eating behavior.

An interesting finding in our study was that higher mean scores in ‘Oral’ sensory processing were positively associated with higher mean scores for ‘Desire to Drink’. The CEBQ item statements within the construct of ‘Desire to Drink’ do not specify the type of drinks the child is requesting or consuming, however in a study of 346 preschool children, higher scores in ‘Desire to Drink’ were associated with higher intakes of sugar sweetened beverages (SSBs) [60]. In clinical practice, children with excessive intakes of fluid, either sugar-sweetened or non-sweetened juice-based drinks often present with poor appetites and food fussiness. High intakes of fluids are often implicated as a reason for reduced appetite and refusal of meals. To date, research to confirm this assumption is lacking. In previous research of the current cohort, higher scores in ‘Desire to Drink’ were associated with lower scores in diet quality, at both 5 years (n = 306) and at 9–11 years old (n = 244) [61]. This suggests that high intakes of beverages may displace intake of foods that could contribute to a higher quality diet [61].

An explanation for the positive association observed between ‘Oral’ sensory processing and higher scores for ‘Desire to Drink’ could lie in the fact that the sensory properties of fluids may be less challenging texturally to a child with oral hypersensitivity. Fluid texture is generally consistent, which could promote acceptance as opposed to complex textures which are associated with food neophobia and fussy eating [62]. In previous cross-sectional research, a prevalent feeding issue identified in a cohort of 455 preschool children was preferring drinks to food [63]. Ross, Surette [64] identified the importance of including the question ‘My child would rather drink than eat’ in their parental questionnaire developed to identify food texture sensitivity in children. In the current study we did not include information on the type and quantity of fluid the child was consuming in relation to ‘Desire to Drink’. Further research is required to explore relationships between children’s type and volume of fluid intake and how this relates to oral sensory sensitivity and heightened ‘Desire to Drink’, and ultimately how this may contribute to food fussiness.

There is limited research examining the relationship between a child’s social and emotional expressiveness and child appetitive traits. In our research a strong correlation was observed between the ‘Oral’ sensory processing segment of the CSP2 and the ‘Social-Emotional’ responses associated with sensory processing segment. Child ‘Social-Emotional’ responses were positively associated with ‘Desire to Drink’ and the food avoidant behaviors of ‘Emotional Undereating’ and ‘Food Fussiness’. With regard to ‘Food Fussiness’ and ‘Emotional Undereating’, previous work has demonstrated that individual differences in temperament may offer an explanation as to why some children develop food fussiness and others do not [42]. Children who have more emotional temperaments have been shown to display increased negativity at mealtimes and increased food avoidant eating behavior [42, 43, 65]. Being aware of a possible link between heightened ‘Social-Emotional’ responses associated with sensory processing and oral hypersensitivity may be helpful in understanding the sensory challenges that a child is encountering. It also may provide solutions on how to adapt the environment so that heightened sensory stimuli is reduced at mealtimes. However, research has also observed that children with higher emotionality and sensory reactivity are more likely to be perceived by their mothers as fussy eaters [43] and as our data was collected via maternal reported questionnaires, this may have biased our results.

The positive associations observed between ‘Social-Emotional’ responses and the food approach appetitive trait of ‘Desire to Drink’ may be reflective of the strong correlation between ‘Social Emotional’ responses to sensory processing and ‘Oral’ sensory processing observed in this cohort. Higher scores in both ‘Oral’ sensory processing and ‘Social Emotional’ responses were associated with higher mean scores in ‘Food Fussiness’ and ‘Desire to Drink’. As previous studies have observed that higher emotionality, anxiety and stress may result in higher consumption of food and beverages [66, 67], it was of interest that no relationship was observed between ‘Social-Emotional’ responses and ‘Emotional Overeating’. In this analysis we controlled for breastfeeding exposure and timing of introduction of complementary feeding as both have previously been demonstrated to impact child appetitive traits [35, 68]. However, we did not control for parental feeding practices. Responsive feeding practices encourage a child to self-regulate food and beverage intake. Non-responsive parental feeding practices often involve using food or drink in infancy and early childhood to placate heighted emotions [69]. This can disrupt a child’s self-regulation and promote the use of food to manage emotions. Furthermore, a higher emotional temperament in childhood has been linked with increased weight status and BMI z-score [70].

To our knowledge, the relationship between maternal sensory and child sensory profiles has not been explored to date. A small number of studies have examined associations between maternal eating behavior and child appetitive traits [35, 71]. Yelverton, Geraghty [35] observed a positive association between maternal ‘Emotional Eating’ and child ‘Emotional Over and Undereating’ at 5 years old (n = 230) [35]. Another study of 305 mother- child pairs (8–17 years old) observed that mothers and offspring shared similar disinhibited eating behaviours [71]. We observed a positive relationship between maternal and child ‘Sensory sensitivity’, ‘Avoidant’ and ‘Low registration’ sensory processing quadrants. As sensory processing patterns are thought to be inherent [2], these findings are not completely unexpected. However, an integral part of how a child learns to eat and drink is established through modelling the behaviors of parents and caregivers. Maternal ‘Sensation avoiding’ accounted for 16% of variance explained for the child ‘Avoiding/Avoider’ variable within the model. Our results pose the question as to what extent environmental factors, as opposed to genetic factors, influence a child’s sensory profile and whether a child’s sensory behaviors may mirror maternal behaviors. Further exploration is required to evaluate what proportion of sensory processing patterns are learned or shaped by the child’s role models.

Strengths of this study include the use of validated questionnaires to measure child appetitive traits and maternal and child sensory profiles. The availability of maternal information and demographics from the original ROLO pregnancy study, in combination with the 5-year-old and 9–11-year follow-up data, allowed for adjustment of important potential confounders in the analyses. We applied the Benjamini-Hochberg false discovery rate to adjust for multiple testing. The present study is not without limitations. This study is cross-sectional and exploratory in design, and therefore a power calculation was not performed. The questionnaires used to measure child appetitive traits and maternal and child sensory profiles were based on maternal self-report rather than direct observation of children’s appetitive traits and sensory processing patterns. Mothers may make assumptions about their children’s appetitive traits and sensory processing patterns. The use of the Short Sensory Profile 2 [72] which has been used in several other studies would have allowed better comparison with previous studies. However, use of the A/ASP and CSP2 allowed examination of associations between maternal and child sensory profile quadrants. Including data on the type and volume of drinks children were consuming in relation to the appetitive trait of ‘Desire to Drink’ within our analysis would have strengthened the interpretation of our findings. The majority of data were collected during the COVID-19 pandemic (2020–2022), although researchers instructed mothers to complete questionaries relating to their behviour pre-COVID-19, its influence may still have been present. While 432 participants returned for the ROLO Preteen follow-up, a much smaller number of participants completed both the CEBQ and the sensory profiles, therefore reducing our sample size. Finally, our sample may not be fully representative of the general population as the sample included a high proportion of mothers that had achieved tertiary or higher education level. In addition, as per the selection criteria for the original RCT, all children were second born children whose older sibling weighed over 4 kg at birth. This may have resulted in a cohort who are potentially obesogenic.

Conclusion

Our findings highlight the need for increased awareness of the potential influence of oral sensory hypersensitivity and higher scores in ‘social-emotional’ sensory responses in typically developing children who presents with fussy eating. Identifying early modifiable factors that predispose fussy eating behavior could be valuable in providing direction on how to address sensitivity and ultimately improve dietary intake. The associations observed between both ‘Oral’ and ‘Social-Emotional’ sensory responses and ‘Desire to Drink’ require further investigation to elucidate how this may impact overall food intake. A deeper awareness and consideration of maternal sensory processing patterns and how they may influence their offspring’s sensory processing patterns could help provide a clearer understanding of their child’s eating behavior.

Data availability

The datasets used and analyzed during the current study are not publicly available in line with ethical approval but are available from the corresponding author on reasonable request.

Abbreviations

ROLO:

Randomized cOntrol trial of a LOw glycaemic index diet in pregnancy to prevent macrosomia

CEBQ:

Childrens Eating Behaviour Questionnaire

A/ASP:

Adolescent/Adult Sensory Profile

CSP2:

Child Sensory Profile 2

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Acknowledgements

The authors would like to thank all the parents and children of the ROLO study for their continued support. Thank you also to the staff of the National Maternity Hospital for facilitating our research.

Funding

The ROLO study was funded by the Health Research Board Ireland, the Health Research Centre for Health and Diet Research, The National Maternity Hospital Medical Fund and the European Union’s Seventh Framework Programme (FP7/2007–2013), project Early Nutrition under grant agreement no. 289346. The ROLO Preteen study was funded by the National Children’s Research Centre Ireland at Children’s Health Ireland, grant number PRPG/H/18/325. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Authors and Affiliations

  1. UCD Perinatal Research Centre, School of Medicine, University College Dublin, The National Maternity Hospital, Dublin 2, Ireland

    Anna Delahunt, Sophie Callanan, Eileen C. O’ Brien, Aisling A. Geraghty, Sharleen L. O’ Reilly, Emma Hokey & Fionnuala M. McAuliffe

  2. School of Biological and Health Sciences, Technological University Dublin, Dublin, Ireland

    Eileen C. O’ Brien

  3. School of Agriculture and Food Science, University College Dublin, Dublin 4, Ireland

    Sharleen L. O’ Reilly

  4. Department of Paediatric Endocrinology & Diabetes, Children’s Health Ireland Temple St & Tallaght, Dublin, Ireland

    Ciara M. McDonnell

  5. Discipline of Paediatrics, School of Medicine, Trinity Research in Childhood Centre (TRICC), Trinity College, Dublin, Ireland

    Ciara M. McDonnell

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Contributions

AD and FMcA were responsible for the project conception, AD, SOR, CMD and FMcA designed the research and analysis plan, SC, EOB, AG, EH and AD and collected the data. AD analyzed the data and performed statistical analysis, AD wrote the paper and all authors reviewed and approved the final manuscript.

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The ROLO longitudinal birth cohort studies were carried out in accordance with the Helsinki Declaration of 1975 as revised in 1983 with institutional ethical approval from the National Maternity Hospital in November 2006 for the primary ROLO study and for the follow-up at 6 months and 2-year in May 2009. The Current Controlled Trials registration number for the ROLO study was ISRCTN54392969. The ROLO Kids 5-year follow-up were approved by the Ethics (Medical Research) Committee in Our Lady’s Children’s Hospital, Dublin, REC reference: GEN/279/12. Ethical approval for the ROLO Preteen follow-up was obtained from the University College Dublin, Office of Research Ethics Committee, Dublin, Ireland, REC reference: GEN/279/12.

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Delahunt, A., Callanan, S., O’ Brien, E.C. et al. Sensory processing and child appetitive traits: findings from the ROLO longitudinal birth cohort study. Nutr J 23, 136 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12937-024-01040-1

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