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Few clinical presentations demand more nuanced intervention than the underweight child with selective eating. These are not simply “picky eaters.” Many exhibit entrenched feeding difficulties—sensory sensitivities, food rigidity, gut dysfunction, or features of avoidant/restrictive food intake disorder (ARFID). These children often fail to meet energy requirements through food alone, despite dietetic support and family-centered strategies. As practitioners, we face a delicate question: when does a therapeutic diet need to be supplemented, and is there evidence to support that approach?
A newly published systematic review and meta-analysis in Clinical Nutrition ESPEN (2025) adds important clarity to this discussion. The authors evaluated five randomized controlled trials involving 874 children who were underweight and had feeding difficulties. In all studies, participants received either dietetic consultation (DC) alone or DC combined with oral nutritional supplements (ONS). Interventions typically lasted between three and six months, focusing on children whose weight-for-age or weight-for-height scores were suboptimal.
➣ Anthropometric improvement: Children in the ONS + dietetic counseling (DC) group demonstrated significantly greater improvements in weight-for-height and weight-for-age z-scores compared to those receiving DC alone. This suggests that ONS can effectively augment caloric and nutrient intake in children unable to meet energy requirements through diet alone.
➣ Reduced incidence of upper respiratory tract infections (URTIs): Two RCTs (n=359) reported a lower risk of URTIs in the ONS group (relative risk ~0.62), with a calculated number needed to treat (NNT) of approximately 10. While causality cannot be established, this may reflect improved micronutrient status or macronutrient support enhancing mucosal immunity and systemic immune resilience.
➣ Acceptable safety profile: Across the included studies, no significant increase in adverse events was observed with ONS use over 90 or 180 days. This supports short- to mid-term safety in undernourished pediatric populations, particularly when products are selected and dosed appropriately.
Together, these findings suggest that ONS, when paired with dietary intervention, may accelerate catch-up growth and confer additional systemic benefit—a valuable tool in the hands of the integrative clinician.
Despite the clinical promise, several limitations warrant attention:
→ Heterogeneity of feeding profiles: The trials encompassed a broad range of children labeled as “picky eaters,” but few provided granular data on neurodevelopmental status, sensory sensitivities, or comorbid feeding diagnoses. This reduces the specificity of applicability across subtypes (e.g., ARFID vs behavioral picky eating).
→ Inconsistency in linear growth and BMI outcomes: While weight-related indices improved, effects on height velocity and BMI were inconsistent, raising questions about the quality of weight gain and long-term trajectory of growth.
→ Lack of long-term follow-up: The available data reflect interventions lasting up to six months. There is limited evidence on the sustainability of growth improvements post-supplementation, or on potential risks of prolonged use.
→ Variation in ONS formulations and dosing protocols: Studies used different products, macronutrient profiles, and dosing frequencies. No standardized guidance on optimal formulation (e.g., protein content, micronutrient spectrum, additive load) can yet be drawn from the data.
These findings reinforce the judicious use of oral supplementation as a clinical bridge—not a replacement for food or therapeutic feeding work, but a temporary adjunct to restore nutritional adequacy while addressing underlying drivers of disordered eating. When a child is not growing, immune-compromised, and at nutritional risk, carefully selected ONS can be part of a structured plan that includes ongoing behavioral feeding therapy, nutritional counseling, and root-cause exploration. Product selection should emphasize clean ingredients and appropriate macronutrient balance, while communication with families must frame ONS as a therapeutic intervention rather than a long-term nutritional solution.
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