Int J Clin Pediatr

International Journal of Clinical Pediatrics, ISSN 1927-1255 print, 1927-1263 online, Open Access

Article copyright, the authors; Journal compilation copyright, Int J Clin Pediatr and Elmer Press Inc

Journal website https://www.theijcp.org

Original Article

Volume 13, Number 3, December 2024, pages 73-85

Feeding Behaviors Among Children With Autism Spectrum Disorder

Figure 1. Feeding difficulty classification among patients (BAMBI, n = 341). BAMBI: Brief Autism Mealtime Behavior Inventory.

Figure 2. Feeding difficulty classification among patients (MCH-FS, n = 341). MCH-FS: Montreal Children’s Hospital Feeding Scale.

**Table 1.** Demographic and Socioeconomic Characteristics of the Sample (N = 341)
Characteristics	N (%)
Y: year; M: month; SCI: social communication interaction; RRB: repetitive, restricting behavior; BMI: body mass index; RM: Malaysian ringgit.
Age
1Y - 1Y 11M	1 (0.3%)
2Y - 2Y 11M	48 (14.1%)
3Y - 3Y 11M	56 (16.4%)
4Y - 4Y 11M	65 (19.1%)
5Y - 5Y 11M	65 (19.1%)
6Y - 6Y 11M	106 (31.1%)
Gender
Male	241 (70.7%)
Female	100 (29.3%)
Ethnicity
Malay	229 (67.2%)
Chinese	57 (16.7%)
Indian	55 (16.1%)
BMI categories by percentile
Underweight	86 (25.2%)
Normal	197 (57.8%)
Overweight	27 (7.9%)
Obese	31 (9.1%)
SCI
1	29 (8.5%)
2	266 (78.0%)
3	46 (13.5%)
RRB
1	152 (44.6%)
2	185 (54.3%)
3	4 (1.2%)
Paternal age category
20 - 30 years	42 (12.3%)
31 - 40 years	231 (67.7%)
41 - 50 years	62 (18.2%)
More than 50 years	6 (1.8%)
Father’s education
Primary education	3 (0.9%)
Secondary education	94 (27.6%)
Diploma	80 (23.5%)
Bachelor’s degree	129 (37.8%)
Master’s degree	35 (10.3%)
Maternal age category
20 - 30 years	46 (13.5%)
31 - 40 years	248 (72.7%)
41 - 50 years	44 (12.9%)
More than 50 years	3 (0.9%)
Mother’s education
Primary education	3 (0.9%)
Secondary education	76 (22.3%)
Diploma	96 (28.2%)
Bachelor’s degree	132 (38.7%)
Master’s degree	34 (10.0%)
Total monthly income
Less than RM 3,000	24 (7.0%)
RM 3,000 - 5,000	83 (24.3%)
RM 5,000 - 10,000	126 (37.0%)
RM 10,000 - 15,000	85 (24.9%)
RM 15,000 - 20,000	11 (3.2%)
More than RM 20,000	12 (3.5%)
Relationship of respondent
Parent	243 (71.3%)
Other relative	96 (28.2%)
Caregiver	2 (0.6%)

Table 1. Demographic and Socioeconomic Characteristics of the Sample (N = 341)

Characteristics

N (%)

Y: year; M: month; SCI: social communication interaction; RRB: repetitive, restricting behavior; BMI: body mass index; RM: Malaysian ringgit.

Age

1Y - 1Y 11M

1 (0.3%)

2Y - 2Y 11M

48 (14.1%)

3Y - 3Y 11M

56 (16.4%)

4Y - 4Y 11M

65 (19.1%)

5Y - 5Y 11M

65 (19.1%)

6Y - 6Y 11M

106 (31.1%)

Gender

Male

241 (70.7%)

Female

100 (29.3%)

Ethnicity

Malay

229 (67.2%)

Chinese

57 (16.7%)

Indian

55 (16.1%)

BMI categories by percentile

Underweight

86 (25.2%)

Normal

197 (57.8%)

Overweight

27 (7.9%)

Obese

31 (9.1%)

SCI

29 (8.5%)

266 (78.0%)

46 (13.5%)

RRB

152 (44.6%)

185 (54.3%)

4 (1.2%)

Paternal age category

20 - 30 years

42 (12.3%)

31 - 40 years

231 (67.7%)

41 - 50 years

62 (18.2%)

More than 50 years

6 (1.8%)

Father’s education

Primary education

3 (0.9%)

Secondary education

94 (27.6%)

Diploma

80 (23.5%)

Bachelor’s degree

129 (37.8%)

Master’s degree

35 (10.3%)

Maternal age category

20 - 30 years

46 (13.5%)

31 - 40 years

248 (72.7%)

41 - 50 years

44 (12.9%)

More than 50 years

3 (0.9%)

Mother’s education

Primary education

3 (0.9%)

Secondary education

76 (22.3%)

Diploma

96 (28.2%)

Bachelor’s degree

132 (38.7%)

Master’s degree

34 (10.0%)

Total monthly income

Less than RM 3,000

24 (7.0%)

RM 3,000 - 5,000

83 (24.3%)

RM 5,000 - 10,000

126 (37.0%)

RM 10,000 - 15,000

85 (24.9%)

RM 15,000 - 20,000

11 (3.2%)

More than RM 20,000

12 (3.5%)

Relationship of respondent

Parent

243 (71.3%)

Other relative

96 (28.2%)

Caregiver

2 (0.6%)

**Table 2.** BAMBI Results With Comparison to Populations of Different Ethnicity
Studies	This study	Kang et al [11]	Gray et al [19]	Lukens et al [15]	Lukens et al [15]
Values are presented as means (SD). Significance was denoted as P < 0.05 and *P < 0.01. Differences were assessed with two-sample t-test for BAMBI scores compared between groups. BAMBI: Brief Autism Mealtime Behavior Inventory; SD: standard deviation; ASD: autism spectrum disorder.
N	341	64	31	68	40
Age	1 - 6 years 11 months	1 - 7 years	3 - 12 years	3 - 11 years	3 - 11 years
Race	Malaysian (current study)	Asian (Singapore)	Chinese American	Predominantly White American	Predominantly White American
Developmental condition	ASD	ASD	ASD	ASD	Typical developing
Total score	41.46 (11.62)	40.8 (9.1)	43.59 (11.91)	49.05 (10.33)**	32.50 (8.59)**
Limited variety	22.36 (6.68)	20.7 (5.3)	23.17 (6.61)	27.61 (6.79)**	17.83 (5.65)**
Food refusal	9.49 (4.12)	11.2 (3.3)	9.33 (3.63)	10.36 (3.74)	6.93 (2.77)**
Features of autism	9.61 (3.53)	8.8 (3.4)	11.09 (3.44)*	11.07 (3.49)**	7.75 (1.66)*

Table 2. BAMBI Results With Comparison to Populations of Different Ethnicity

Studies

This study

Kang et al [11]

Gray et al [19]

Lukens et al [15]

Values are presented as means (SD). Significance was denoted as *P < 0.05 and **P < 0.01. Differences were assessed with two-sample t-test for BAMBI scores compared between groups. BAMBI: Brief Autism Mealtime Behavior Inventory; SD: standard deviation; ASD: autism spectrum disorder.

341

Age

1 - 6 years 11 months

1 - 7 years

3 - 12 years

3 - 11 years

Race

Malaysian (current study)

Asian (Singapore)

Chinese American

Predominantly White American

Developmental condition

ASD

Typical developing

Total score

41.46 (11.62)

40.8 (9.1)

43.59 (11.91)

49.05 (10.33)**

32.50 (8.59)**

Limited variety

22.36 (6.68)

20.7 (5.3)

23.17 (6.61)

27.61 (6.79)**

17.83 (5.65)**

Food refusal

9.49 (4.12)

11.2 (3.3)

9.33 (3.63)

10.36 (3.74)

6.93 (2.77)**

Features of autism

9.61 (3.53)

8.8 (3.4)

11.09 (3.44)*

11.07 (3.49)**

7.75 (1.66)*

**Table 3.** Comparison of MCH-FS Questionnaire Item Scores Across Different Populations
Item	This study (mean ± SD)	Benjasunwatep et al [18] (mean ± SD)	Ramsay et al [1] (mean ± SD)	van Dijk [9] (mean ± SD)
SD: standard deviation; MCH-FS: Montreal Children’s Hospital Feeding Scale.
Population	Malaysian clinical sample (1 - 6 years 11 months)	Thai children (1 - 4 years)	Canadian clinical sample (6 months - 6 years 11 months)	Dutch clinical sample (1 - 6 years)
N	341	200	174	80
M1	3.20 ± 1.70	2.65 ± 1.84	5.30 ± 1.53	3.99 (1.47)
M2	3.76 ± 2.00	2.94 ± 2.03	5.49 ± 1.59	2.67 (1.72)
M3	2.91 ± 1.48	2.68 ± 1.68	4.60 ± 1.51	3.47 (1.29)
M4	4.02 ± 2.32	2.75 ± 1.80	5.42 ± 1.67	4.90 (2.06)
M5	2.83 ± 1.27	2.25 ± 1.75	3.57 ± 1.84	2.44 (1.30)
M6	3.07 ± 1.68	2.63 ± 1.65	4.60 ± 1.80	3.15 (1.47)
M7	2.88 ± 1.63	2.32 ± 1.70	4.02 ± 2.04	2.66 (1.87)
M8	2.78 ± 1.96	2.62 ± 1.97	3.55 ± 2.08	2.45 (1.80)
M9	3.54 ± 2.13	3.30 ± 2.10	4.91 ± 2.16	3.10 (1.65)
M10	3.17 ± 1.93	2.64 ± 1.88	4.64 ± 2.04	2.84 (1.65)
M11	2.43 ± 1.82	1.49 ± 1.09	3.32 ± 2.09	3.31 (1.67)
M12	2.94 ± 1.76	2.15 ± 1.54	4.14 ± 2.05	2.45 (1.92)
M13	2.88 ± 1.85	1.87 ± 1.43	3.37 ± 1.89	2.10 (1.44)
M14	2.91 ± 1.85	1.76 ± 1.46	3.56 ± 1.99	2.50 (1.78)
Total	43.32 ± 14.74	34.01 ± 13.65	60.48 ± 13.04	39.96 (12.52)

Table 3. Comparison of MCH-FS Questionnaire Item Scores Across Different Populations

Item

This study (mean ± SD)

Benjasunwatep et al [18] (mean ± SD)

Ramsay et al [1] (mean ± SD)

van Dijk [9] (mean ± SD)

SD: standard deviation; MCH-FS: Montreal Children’s Hospital Feeding Scale.

Population

Malaysian clinical sample (1 - 6 years 11 months)

Thai children (1 - 4 years)

Canadian clinical sample (6 months - 6 years 11 months)

Dutch clinical sample (1 - 6 years)

341

200

174

3.20 ± 1.70

2.65 ± 1.84

5.30 ± 1.53

3.99 (1.47)

3.76 ± 2.00

2.94 ± 2.03

5.49 ± 1.59

2.67 (1.72)

2.91 ± 1.48

2.68 ± 1.68

4.60 ± 1.51

3.47 (1.29)

4.02 ± 2.32

2.75 ± 1.80

5.42 ± 1.67

4.90 (2.06)

2.83 ± 1.27

2.25 ± 1.75

3.57 ± 1.84

2.44 (1.30)

3.07 ± 1.68

2.63 ± 1.65

4.60 ± 1.80

3.15 (1.47)

2.88 ± 1.63

2.32 ± 1.70

4.02 ± 2.04

2.66 (1.87)

2.78 ± 1.96

2.62 ± 1.97

3.55 ± 2.08

2.45 (1.80)

3.54 ± 2.13

3.30 ± 2.10

4.91 ± 2.16

3.10 (1.65)

M10

3.17 ± 1.93

2.64 ± 1.88

4.64 ± 2.04

2.84 (1.65)

M11

2.43 ± 1.82

1.49 ± 1.09

3.32 ± 2.09

3.31 (1.67)

M12

2.94 ± 1.76

2.15 ± 1.54

4.14 ± 2.05

2.45 (1.92)

M13

2.88 ± 1.85

1.87 ± 1.43

3.37 ± 1.89

2.10 (1.44)

M14

2.91 ± 1.85

1.76 ± 1.46

3.56 ± 1.99

2.50 (1.78)

Total

43.32 ± 14.74

34.01 ± 13.65

60.48 ± 13.04

39.96 (12.52)

**Table 4.** Cross-Tabulation of SCI With Feeding Difficulty Classification (BAMBI)
SCI	No feeding difficulty (raw score < 34)	Feeding difficulty (raw score 34 and above)	Total
Chi-square tests: Pearson Chi-square: 0.520, df = 2, P = 0.771; Fisher’s exact test: P = 0.802. BAMBI: Brief Autism Mealtime Behavior Inventory; SCI: social communication interaction.
1	7 (24.1%)	22 (75.9%)	29
2	75 (28.2%)	191 (71.8%)	266
3	11 (23.9%)	35 (76.1%)	46
Total	93 (27.3%)	248 (72.7%)	341

Table 4. Cross-Tabulation of SCI With Feeding Difficulty Classification (BAMBI)

SCI

No feeding difficulty (raw score < 34)

Feeding difficulty (raw score 34 and above)

Total

Chi-square tests: Pearson Chi-square: 0.520, df = 2, P = 0.771; Fisher’s exact test: P = 0.802. BAMBI: Brief Autism Mealtime Behavior Inventory; SCI: social communication interaction.

7 (24.1%)

22 (75.9%)

75 (28.2%)

191 (71.8%)

266

11 (23.9%)

35 (76.1%)

Total

93 (27.3%)

248 (72.7%)

341

**Table 5.** Cross-Tabulation of RRB With Feeding Difficulty Classification (BAMBI)
RRB	No feeding difficulty (raw score < 34)	Feeding difficulty (raw score 34 and above)	Total
Chi-square tests: Pearson Chi-square: 6.470, df = 2, P = 0.039; Fisher’s exact test: P = 0.040. BAMBI: Brief Autism Mealtime Behavior Inventory; RRB: repetitive, restrictive behavior.
1	51 (33.6%)	101 (66.4%)	152
2	42 (22.7%)	143 (77.3%)	185
3	0 (0.0%)	4 (100.0%)	4
Total	93 (27.3%)	248 (72.7%)	341

Table 5. Cross-Tabulation of RRB With Feeding Difficulty Classification (BAMBI)

RRB

No feeding difficulty (raw score < 34)

Feeding difficulty (raw score 34 and above)

Total

Chi-square tests: Pearson Chi-square: 6.470, df = 2, P = 0.039; Fisher’s exact test: P = 0.040. BAMBI: Brief Autism Mealtime Behavior Inventory; RRB: repetitive, restrictive behavior.

51 (33.6%)

101 (66.4%)

152

42 (22.7%)

143 (77.3%)

185

0 (0.0%)

4 (100.0%)

Total

93 (27.3%)

248 (72.7%)

341

**Table 6.** Cross-Tabulation of SCI With Feeding Difficulty Classification (MCH-FS)
SCI	Not having difficulty raw score 45 and below	Having difficulty raw score > 45	Total
Chi-Square tests: Pearson Chi-square: 0.571, df = 2, P = 0.752; Fisher’s exact test: P = 0.789. SCI: social communication interaction; MCH-FS: Montreal Children’s Hospital Feeding Scale.
1	18 (62.1%)	11 (37.9%)	29
2	146 (54.9%)	120 (45.1%)	266
3	25 (54.3%)	21 (45.7%)	46
Total	189 (55.4%)	152 (44.6%)	341

Table 6. Cross-Tabulation of SCI With Feeding Difficulty Classification (MCH-FS)

SCI

Not having difficulty raw score 45 and below

Having difficulty raw score > 45

Total

Chi-Square tests: Pearson Chi-square: 0.571, df = 2, P = 0.752; Fisher’s exact test: P = 0.789. SCI: social communication interaction; MCH-FS: Montreal Children’s Hospital Feeding Scale.

18 (62.1%)

11 (37.9%)

146 (54.9%)

120 (45.1%)

266

25 (54.3%)

21 (45.7%)

Total

189 (55.4%)

152 (44.6%)

341

**Table 7.** Cross-Tabulation of RRB With Feeding Difficulty Classification (MCH-FS)
RRB	Not having difficulty raw score 45 and below	Having difficulty raw score > 45	Total
Chi-square tests results: Pearson Chi-square: value = 6.568, df = 2, P = 0.037; Fisher’s exact test: P = 0.026. Two cells (33.3%) have an expected count less than 5, which influences the test’s validity, and it is likely why Fisher’s exact test is also presented. RRB: repetitive, restrictive behavior; MCH-FS: Montreal Children’s Hospital Feeding Scale.
1	95 (62.5%)	57 (37.5%)	152
2	93 (50.3%)	92 (49.7%)	185
3	1 (25.0%)	3 (75.0%)	4
Total	189 (55.4%)	152 (44.6%)	341

Table 7. Cross-Tabulation of RRB With Feeding Difficulty Classification (MCH-FS)

RRB

Not having difficulty raw score 45 and below

Having difficulty raw score > 45

Total

Chi-square tests results: Pearson Chi-square: value = 6.568, df = 2, P = 0.037; Fisher’s exact test: P = 0.026. Two cells (33.3%) have an expected count less than 5, which influences the test’s validity, and it is likely why Fisher’s exact test is also presented. RRB: repetitive, restrictive behavior; MCH-FS: Montreal Children’s Hospital Feeding Scale.

95 (62.5%)

57 (37.5%)

152

93 (50.3%)

92 (49.7%)

185

1 (25.0%)

3 (75.0%)

Total

189 (55.4%)

152 (44.6%)

341

**Table 8.** Comparison Between Normal and Underweight ASD Children With Overweight and Obese ASD Children Based on Domains of BAMBI and MCH-FS
Factor/domain	Normal and underweight (n = 283), median (IQR)	Overweight and obese (n = 58), median (IQR)	P value
Median values are accompanied by the IQR in parentheses. P values are derived from the Mann-Whitney U test comparing the normal and underweight group with the overweight and obese group across various factors and domains. Statistically significant differences (P < 0.05) are noted. IQR: interquartile range. BAMBI: Brief Autism Mealtime Behavior Inventory; ASD: autism spectrum disorder; MCH-FS: Montreal Children’s Hospital Feeding Scale.
BAMBI and domains
BAMBI total score	40.00 (16)	43.00 (15)	0.034
1) Limited variety	22.00 (11)	25.50 (9)	0.003
2) Food refusal	8.00 (6)	8.50 (5)	0.844
3) Features of autism	9.00 (5)	10.00 (5)	0.343
MCH and domains
MCH total score	43.00 (21)	38.00 (24)	0.072
1) Parental concern	10.00 (6)	7.50 (8)	0.007
2) Family reaction	6.00 (6)	4.00 (6)	0.149
3) Compensatory strategy	10.00 (6)	8.00 (6)	0.018
4) Appetite	7.00 (4)	8.00 (5)	0.871
5) Mealtime behavior	6.00 (5)	6.00 (5)	0.679
6) Oral sensory	6.00 (5)	6.00 (5)	0.594
7) Oral motor	5.00 (6)	4.50 (6)	0.918

Table 8. Comparison Between Normal and Underweight ASD Children With Overweight and Obese ASD Children Based on Domains of BAMBI and MCH-FS

Factor/domain

Normal and underweight (n = 283), median (IQR)

Overweight and obese (n = 58), median (IQR)

P value

Median values are accompanied by the IQR in parentheses. P values are derived from the Mann-Whitney U test comparing the normal and underweight group with the overweight and obese group across various factors and domains. Statistically significant differences (P < 0.05) are noted. IQR: interquartile range. BAMBI: Brief Autism Mealtime Behavior Inventory; ASD: autism spectrum disorder; MCH-FS: Montreal Children’s Hospital Feeding Scale.

BAMBI and domains

BAMBI total score

40.00 (16)

43.00 (15)

0.034

1) Limited variety

22.00 (11)

25.50 (9)

0.003

2) Food refusal

8.00 (6)

8.50 (5)

0.844

3) Features of autism

9.00 (5)

10.00 (5)

0.343

MCH and domains

MCH total score

43.00 (21)

38.00 (24)

0.072

1) Parental concern

10.00 (6)

7.50 (8)

0.007

2) Family reaction

6.00 (6)

4.00 (6)

0.149

3) Compensatory strategy

10.00 (6)

8.00 (6)

0.018

4) Appetite

7.00 (4)

8.00 (5)

0.871

5) Mealtime behavior

6.00 (5)

0.679

6) Oral sensory

6.00 (5)

0.594

7) Oral motor

5.00 (6)

4.50 (6)

0.918

**Table 9.** Crosstabulation of Feeding Difficulty Classification on BAMBI and MCH-FS
Feeding difficulty classification (BAMBI) vs. (MCH)	Reported no feeding difficulty (raw score < 45)	Reported having difficulty (raw score > 45)	Total
BAMBI: Brief Autism Mealtime Behavior Inventory; MCH-FS: Montreal Children’s Hospital Feeding Scale.
Reported no feeding difficulty (raw score < 34)	83 (43.9%)	10 (6.6%)	93 (27.3%)
Reported feeding difficulty (raw score > 34)	106 (56.1%)	142 (93.4%)	248 (72.7%)
Total	189 (100.0%)	152 (100.0%)	341 (100.0%)

Table 9. Crosstabulation of Feeding Difficulty Classification on BAMBI and MCH-FS

Feeding difficulty classification (BAMBI) vs. (MCH)

Reported no feeding difficulty (raw score < 45)

Reported having difficulty (raw score > 45)

Total

BAMBI: Brief Autism Mealtime Behavior Inventory; MCH-FS: Montreal Children’s Hospital Feeding Scale.

Reported no feeding difficulty (raw score < 34)

83 (43.9%)

10 (6.6%)

93 (27.3%)

Reported feeding difficulty (raw score > 34)

106 (56.1%)

142 (93.4%)

248 (72.7%)

Total

189 (100.0%)

152 (100.0%)

341 (100.0%)