Lesson 6: Infants and Toddlers - Additional Feeding Considerations

Introduction

In the last two lessons I presented information regarding breastfeeding, formula feeding, and complementary feeding as they pertain to child health and in particular weight outcomes. Regardless of the actual foods and drinks that are provided to an infant and then toddler, the manner of feeding and the behavior of feeding are separate considerations (compared to the nutrition itself) that may influence weight management and overall health outcomes. I will discuss these topics in this lesson.

Responsive feeding

As recently reviewed, responsive feeding can be defined as “feeding practices that encourage the child to eat autonomously and in response to physiological and developmental needs, which may encourage self-regulation in eating and support cognitive, emotional, and social development.”⁽^{Pérez-Escamilla, 2021)} That publication includes a nice summary table with advice regarding responsive feeding, which I have reproduced below.

Potential mechanisms of benefit

As indicated in the table, feeding to soothe is not recommended. The idea here is that infants can be fussy for a variety of reasons and if you simply provide breast milk or formula every single time then the infant will consume more nutrition than necessary as well as have trouble developing appropriate responses to hunger and satiation signals.

In a 2020 review the authors discussed the roles of the sympathetic and parasympathetic nervous systems as they pertain to self-regulation and highlighted that in infancy more affective and behavioral synchrony between infants and caregivers may help drive better parasympathetic nervous system activity.^{(Hodges, 2020)} This increased parasympathetic nervous system activity may aid emotional regulation and self-control. Thus, positive parenting interactions, which occur frequently when responsive feeding is utilized, may enhance self-regulation far into the future. The authors note that more evidence is needed to support this hypothesis, but this may be one mechanism by which responsive feeding can yield health benefits.

Caregivers can improve at responsive feeding

Some caregivers are able to engage in responsive feeding more easily than others, due to differences in the child’s temperament, cultural background, goals for the child, and likely other reasons. Thankfully, a 2021 systematic review (“SR”) including 43 studies suggested that a caregiver’s ability to engage in responsive feeding can improve^{(Redsell, 2021)}:

This analysis attempted to identify barriers and enablers of responsive feeding. The most prominent enabling skill was being able to recognize feeding cues. Barriers in particular included having goals for how much the child would consume as well as having concerns about the child weighing too little or too much.
Importantly, overall provision of information & education, often in the form of anticipatory guidance & support, was a key enabler for responsive feeding, which implies that when taught how to engage in responsive feeding caregivers can improve with this ability.

The impact of responsive feeding on child health outcomes

There is also research evaluating whether or not responsive feeding has a meaningful impact on outcomes:

A 2019 cohort study found that infants with parents who engaged in feeding to soothe developed a greater zBMI, zFFMI, and zFMI at age 10 years as well as greater emotional eating at age 4 years and 10 years.^{(Jansen, 2019)} The increase in zBMI was relatively small at 0.13 (corresponding to 0.40 BMI points).
- “zBMI” stands for the BMI z-score; z-scores were defined in Lesson 4 but indicate the standard deviation score. “BMI” = body mass index (weight in kilograms divided by height in meters squared (kg/m²)), “FFMI” = fat-free mass index, and “FMI” = fat mass index. FFMI and FMI are calculated similarly to BMI but when only considering the fat-free mass and fat mass, respectively.
A 2019 SR including 27 articles discussed caregiver feeding practices and child weight outcomes^{(Spill, 2019a)}:
- Of these 27 articles, 4 trials aimed to improve eating habits & decrease excessive weight gain by educating parents about infant feeding practices (presumably using responsive feeding); all 4 of these were successful in at least one weight-related outcome in the short term.
  - Thus, it seems responsive feeding guidance is helpful to teach caregivers to recognize and respond to infant hunger/satiation cues and this can assist “normal” weight gain.
- However, 5/6 longitudinal cohort studies that involved responsive feeding found no impact on child weight outcomes. There were mixed results for pressuring to eat, restrictive feeding, feeding in the absence of hunger, feeding to soothe, and indulgent feeding practices.
  - As these were longitudinal studies and not trials, it seems that longitudinal feeding practices typically are related to and potentially result from the caregivers’ concerns of the child’s body weight (ie, more pressuring if the weight is perceived as too low, more restricting if the weight is perceived as too high). Thus, in lieu of an intervention the child’s growth and concerns about the growth may drive the feeding style as opposed to the feeding style influencing growth directly.
A 2021 review of feeding practices in infancy and later childhood eating behaviors noted that randomized controlled trials indicate that infants of mothers who receive responsive feeding guidance have lower BMI z-scores as toddlers and less overweight & obesity at age 3 years.^{(Pang, 2021)} These children also tend to breastfeed for longer periods of time while undergoing less pressuring to eat and less time spent using food as a reward.

Note: Of interest, a 2022 and 2023 systematic review & meta-analysis by the same author group found that^{(Wang, 2022a; Wang, 2023)}:

when parents are concerned for their children being overweight they are more likely to engage in restrictive feeding practices
when parents are concerned for their children being underweight they are more likely to pressure them to eat

These are both non-responsive feeding practices. While parents may be doing what they think is best to “correct” what they perceive to be a problem, it is possible they are doing so in a suboptimal fashion. It can be helpful to understand how to engage in responsive feeding and tailor this to child’s specific situation to help avoid any inadvertent negative health outcomes.

However, responsive feeding may not always be the best approach. A 2022 study found that in infants with high food responsiveness, when mothers performed less restrictive feeding the infants were more likely to rapidly gain weight.^{(Shriver, 2022)} Thus, in this instance it would be better to engage in non-responsive practices and be somewhat restricting if the sole desired outcomes was ideal weight gain. More research needs to be done to determine if there are certain strategies such as using slower-flow nipples with bottles to help mitigate this rapid weight gain risk while still following responsive feeding practices, or perhaps responsive feeding is simply not ideal in all situations.

Tip: The above evidence indicates it is possible to positively impact child feeding behavior, but it’s worth considering how difficult this may be in various situations. A 2021 SR of interventions aiming to improve dietary intake in children aged 0-24 months included 17 articles from 12 trials. Many trials had poor patient retention and only 36 of 165 dietary outcomes were statistically significant, which indicates it is challenging to influence dietary behaviors at this age.^{(Butler, 2021)}

Therefore, as the interventions were designed to improve dietary intake, this implies it may be more helpful to ensure healthy dietary intake from very early in life. If children are raised eating/drinking healthily it will likely be much easier to help those healthy habits persist than to correct unhealthy habits in the future. To do this, it is important to ensure that all of the caregivers are on the same page regarding how to approach food selection and feeding in general.

Picky eating

Some children have much more difficulty with picky eating and incorporating a variety of foods than others, due to differences in temperament, bitterness sensitivity, behavioral styles such as inhibitory control or the ability to resist automatic behavioral responses, and other factors. Differences between infants regarding appetite, enjoyment of food, and food responsiveness can be seen before the onset of complementary feeding and persist throughout infancy until the children become toddlers.^{(Russell CG, 2021)} This has implications for overall health as if children are picky and not consuming adequate vitamins, minerals, protein, healthy fats, and other desired nutrients then it stands to reason this may lead to worse health outcomes long-term. For this reason, for significantly picky eating micronutrient supplementation should be considered.

Regarding the impact of picky eating on growth, a 2019 study followed children identified as picky eaters at age 3 until the age of 7-17 years.^{(Taylor, 2019a)} The picky eaters typically had slightly lower weight (1-2.5 kg), body fat percentage (1.5% lower), FFMI (~0.2-0.4 lower), and height (~1-2 cm lower). About 40% of the picky eaters at age 3 remained picky at age 5. Almost 1/5 of the picky eaters had a low BMI at some point compared to 1/10 who were not picky. Even picky eaters on average were above the 50^th percentile on the growth charts. Overall, this is reassuring that the growth of picky eaters is generally normal, which may in part be due to picky eating generally resolving to some degree over time^{(Diamantis, 2023)}, though the small subset that have a low BMI may warrant additional intervention. These thoughts are echoed in a review by these same authors that discuss findings of a handful of other longitudinal studies as well; in particular they highlight that zinc and iron deficiency will be more common in early life so finding a way to supplement these may be useful.^{(Taylor, 2019b)}

With respect to managing picky eating, feeding behaviors, and promoting healthy food preferences, several pieces of literature have been published discussing these topics.^{(Johnson, 2016; Anzman-Frasca, 2018; Spill, 2019b; Patel, 2020; Wood, 2020; Białek-Dratwa, 2022; Costa, 2023; Elmas, 2023)} I will highlight several of the insights they provide in the following sections, though it’s important to realize that there is not a uniform definition of picky eating and its associated traits and the literature base overall requires more methodologically rigorous studies to help determine the most efficacious intervention components in different scenarios.^{(Kamarudin, 2023; Mudholkar, 2023)}

General aspects of picky eating

Genetic and early life influences

The ability to taste certain bitter compounds such as 6-n-propylthiouracil (“PROP”) and phenylthiocarbamide is genetically determined and will influence the child’s response to bitter foods (generally the “tasters” are pickier eaters and dislike more foods). These PROP tasters are more sensitive to sweet tastes and the oral sensation of fattiness.
Traits such as food neophobia and “food fussiness” are highly inheritable.
As mentioned in Lesson 4, breastfeeding can aid in preventing picky eating by introducing a variety of flavors early. As mentioned in Lesson 2 this also extends to pregnancy where women who consume more healthy foods can have these flavors transfer into amniotic fluid. For formula-fed babies the infants generally prefer flavors that are similar to the flavors of the formula they consumed.

Time course

Vegetable acceptance typically peaks during infancy and then declines from age 1 year through preschool.
Sweet taste is preferred in childhood and declines to adult levels in mid-adolescence.
Food preferences acquired during childhood carry into adolescence and can predict diet quality in adulthood.

The benefit of repeated and varied exposures

At least 3-6 exposures may be needed, and at times up to 8-10 or even 10-15 may be more beneficial, prior to a new food being more formally accepted. The number of needed attempts may be greater as the child ages in the toddler and early childhood years (thus, a 4-year old may need more attempts than a 2-year old).
A greater variety of exposures leads to more novel food intake in a similar food category. For example, providing several different fruits and vegetables increases the likelihood that the child will accept additional types of fruits and vegetables but will not impact the likelihood of the child accepting a new type of cheese.
Some exploratory food behaviors may be misconstrued as “bad manners”; it is helpful to allow the young child to interact with the food in a positive fashion. Even if the child just licks the food and then puts it down this is a good first step. Being positive in this instance (ie, saying “Good job tasting the food!”) as opposed to being negative (ie, saying “You need to eat the food” when the child clearly is not interested in eating it) will likely make this a more pleasant and beneficial experience for everyone involved.

Cooking

Cooking can change flavors and may be helpful. For example, during cooking bitter flavonoids & isothiocyanates present in raw broccoli are released which will possibly increase the food’s acceptability.
Cooking also softens textures, which is frequently preferred in children. However, some studies indicate children prefer the crunchy texture of raw vegetables. This may vary based on the child and for vegetables that are difficult to chew there may a benefit from softening them with cooking (purchasing frozen vegetables is also a good option for changing the texture).
Allowing children to participate in cooking can help show them food can be fun and enjoyable, leading them to be more likely to eat what they prepare.

Practical tips

Associative conditioning is a useful strategy; for example, you can pair broccoli with a dip to promote intake of the broccoli, or you can promote new food intake with a small incentive such as a sticker (or points that can be traded in for a prize later for older children). However, if you do this you run the risk of the child only taking the food when the associated benefit is present. This will vary by child but if this is a concern it may be best to only use this strategy for the initial testing or tasting of the food and then wean off of it as the food becomes more accepted.
Modeling is helpful; if caregivers happily eat vegetables in front of their children then the children will be more likely to eat them as well.
Food chaining, where you initially present similar foods but altered in some way (ie, changing the shape of pasta) can be a gentle way to begin introducing greater variety.
Making the healthier options the only available options for snacking purposes can lead to greater acceptance (ie, only allowing snacking with fruits and vegetables).
Offering larger portions of vegetables at the beginning of a meal can be helpful. In general, when there are more fruits and vegetables available more will be consumed.
Combining various strategies is needed for some children. For example, you can provide flavor-flavor learning (where you pair the new food with a liked flavor), provide this repeatedly so there is repeated exposure, present this in a visually-appeasing manner, and provide stickers to help the child be willing to give the new food several attempts. Then you can gradually wean off these strategies as the child more readily accepts the food.

Tip: Remember, some degree of picky eating is normal, and toddlers can change food preferences on a whim. You can use the above strategies to help a child expand their food choices, but there is no reason to expect a young child to like everything. As long as you can select a few foods from each food group for your child to eat, either knowingly or mixed in with other preferred foods, your child will likely not experience any severe nutritional deficiencies. You can always discuss with your child’s healthcare provider if you have any further concerns.

Feeding styles

Feeding styles generally consist of two dimensions: responsiveness and demandingness,. Thus, feeding styles can be split into the following four groups:

Authoritative or responsive:
- high in demandingness & high in responsiveness
- sets boundaries
- uses nondirect strategies to support child autonomy (ie, reasoning, complimenting, controlling the food environment rather than the child (ie, make most available foods nutrient dense, setting mealtimes within which the child can decide if and how much to eat))
Indulgent:
- low in demandingness & high in responsiveness
- allows the child to have whatever the child wants
- associated with higher adiposity (body fat) & lower self-regulation (thus there is a need for boundaries)
- is responsive to child hunger/satiation cues, lack of structure
Authoritarian – can be restrictive or pressuring:
- high in demandingness & low in responsiveness
- sets boundaries
- uses overt behaviors to change child behavior (ie, rewards, punishments), considered directive
Uninvolved or Laissez-faire:
- low in demandingness & low in responsiveness
- few boundaries
- do not respond to hunger/satiety cues

You can lock the refrigerator if needed to set limits and boundaries for older children and adolescents. For toddlers you can also do this but you may be able to simply utilize a sign; you can place different signs to show when it is and is not time to eat.

Authoritative feeding styles are generally considered to be the most beneficial; this entails using negotiation with appropriate demands associated to health goals. For example, you can offer healthy choices within a structured environment that limits the types of available foods and the timing of meals. This has been shown to decrease food neophobia & provide motivation to attempt novel foods. This can be considered progression from responsive feeding done initially with breast milk or formula feeding.

Boundaries should be set covertly; for example, rather than telling a toddler they cannot have a cookie that they see is present, it is better to hide the cookie so that the toddler does not know it is available. Setting boundaries becomes even more critical in the preschool years. Importantly, while this authoritative feeding style seems ideal, it is worth noting that this requires a high level of attention and thought as well as confidence that this will work to help the child accept new foods as long as you put in the time and effort.

On the other hand, indulgent feeding styles (which are very permissive) as well as authoritarian styles are associated with negative mealtime strategies and the perception of picky eating. Pressuring to eat is associated with an impaired ability to self-regulate eating behavior. Restrictive feeding practices are associated with a higher consumption of eating in the absence of hunger as well as higher rates of excess body weight, though it is unclear how much of this is associative vs causative.^{(Khalsa, 2022)}

Of interest, caregivers who endorse crying as a reliable hunger cue are much more likely to have a pressuring feeding style (ie, authoritarian); thus working on responsive feeding during early infancy to better detect hunger cues may assist in more optimal feeding behavior during the toddler and childhood years.

Tip: A 2022 longitudinal study evaluated the relationship between infant/maternal feeding styles and feeding characteristics from 5 to 24 months of age, finding that mothers with greater symptoms of anxiety and depression had greater concerns of their child being overweight and were more likely to use feeding styles including pressuring and emotional feeding.^{(Helle, 2022)} Other research has shown that there can be some influences from child eating styles onto parental feeding behaviors, and vice-versa, though the associations are fairly weak, which may indicate significant variability between different families.^{(Wang, 2022b)}

Therefore, as parental feeding styles can be influenced by non-child-driven factors (ie, parental mental health), and as different children may respond quite differently to any given feeding technique, discussing with your child’s healthcare provider to go over feeding strategies based on your child’s temperament and growth may be helpful.

Considerations of portion sizes and eating in the absence of hunger

If people could regulate their intake perfectly, meaning they would only consume as much nutrition as their body needs, then there would not be a need to worry about portion sizes or eating in the absence of hunger. However, as evidenced by the growing obesity epidemic, it is clear many people consume more nutrition than is necessary. Here I’ll highlight a few publications that indicate this is also a relevant consideration for young children; you can click on the expandable box below for brief overviews of various references or you can skip to a summary paragraph I include underneath the expandable box.

Click here for overviews of recent publications regarding portion sizes and eating in the absence of hunger in young children

Summary:

As the above literature indicates and as recently reviewed^{(Russell A, 2021)}, infants are better able to regulate their own intake appropriately while this ability declines by the preschool ages, and young children are better able to compensate than older children (who are more likely to eat when not hungry), but this compensation is partial and there are significant individual differences. Traits such as food responsiveness and satiety responsiveness seem to correlate well across young childhood ages, implying individual differences may persist longitudinally. Thus, as children age it can be harder to guide them towards appropriate food intake, particularly as prepackaged items and nutrition labels are geared towards adults. Providing appropriate snack and meal sizes with some level of structure to prevent many opportunities to eat when not hungry should be helpful in aiding appropriate growth in young children.

Tip: If you skipped Lesson 5 I provided more specific advice about appropriate portion sizes there.

Conclusion

In the last two lessons I discussed various aspects of breastfeeding, formula feeding, and complementary feeding as they pertain to child weight outcomes and some aspects of general health. In this lesson I discussed various aspects of how to feed a child, including:

various feeding styles that people typically use when feeding an infant and toddler
- generally responsive feeding with an authoritative feeding style is preferred – this entails responding to a child’s hunger and satiation cues while offering appropriate structure and limits to guide them towards healthy eating
tips for addressing picky eating
- generally this includes setting limits for preferred food/drink items, using various strategies to increase food engagement, practicing positive reinforcement, and lots of patience
the importance of providing appropriate portion sizes and limiting eating opportunities
- this will help prevent overeating and excess weight gain

In the next lesson I will discuss implications of infant and toddler growth as well as other pertinent topics related to future childhood obesity risk.

Click here to proceed to Lesson 7

References

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Wood AC, Blissett JM, Brunstrom JM, Carnell S, Faith MS, Fisher JO, Hayman LL, Khalsa AS, Hughes SO, Miller AL, Momin SR, Welsh JA, Woo JG, Haycraft E; American Heart Association Council on Lifestyle and Cardiometabolic Health; Council on Epidemiology and Prevention; Council on Lifelong Congenital Heart Disease and Heart Health in the Young; Council on Cardiovascular and Stroke Nursing; and Stroke Council. Caregiver Influences on Eating Behaviors in Young Children: A Scientific Statement From the American Heart Association. J Am Heart Assoc. 2020 May 18;9(10):e014520. doi: 10.1161/JAHA.119.014520. Epub 2020 May 11. Erratum in: J Am Heart Assoc. 2020 May 18;9(10):e014551. PMID: 32389066; PMCID: PMC7660848.

Lesson 6: Infants and Toddlers – Additional Feeding Considerations

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