Eating behaviour in childhood week/lecture 4/5

Question 1

what is weaning?

Answer 1

Weaning/complementary feeding:
- Major developmental change
○ Milk to solids
○ Sucking to chewing and biting
○ Dependent to independent

Question 2

when are infants weaned?

Answer 2

• Milk energy supply cannot satisfy infant or provide nutrients
  
  • Motor skills are developed sufficiently
  • Major variability
    ○ Thailand: 15% some solids at 2 weeks
    ○ UK: 3% some solids at 6 weeks

Question 3

weaning guidelines

Answer 3

• WHO (2001) recommends weaning at 6 months (because by this point babies can sit and hold themselves and their heads up and reaching behaviours have begun)
  
  • UK department of health adopted this in 2003

Question 4

reality of weaning in the UK

Answer 4

○ 30% introduced solids by 4 months
○ 75% introduced solids by 5 months
○ 94% introduced solids by 6 months
§ 2010 infant feeding survey, DoH, 2013

Question 5

many start weaning earlier due to

Answer 5

○ Belief that baby is hungry
○ To encourage better sleep patterns
○ Following routine used with older offspring

Question 6

oral motor skills and weaning

Answer 6

• Necessary for weaning
  
  • Highly complex: swallowing = 31 muscle pairs (take time to develop/mature enough)
  • Delayed transition to solids - miss this developmental period –> problems
  • Anxieties about choking can delay transition
  • Aspiration can result (if solid feeding is too late): Accidental ingestion of food or fluids into the lungs

Question 7

gag reflex

Answer 7

• Adaptive; prevents choking
  
  • Common in the transition period
  • Not serious; but caregivers can panic
    ○ Gagging; retch and make a lot of noise
    ○ Choking; will be silent
  • Can become hypersensitive:
    ○ Learned from negative experience; e.g. choking
    ○ Generalises to all foods, even sight of food
    ○ Professional help required to ‘unlearn’ response

Question 8

food choice: distinguish between non-edible substances by

Answer 8

○ Sensory qualities of food
○ Anticipated consequences of eating food
§ E.g. poisoning
○ Cultural beliefs
§ Disgust
§ Disease
- Pica (eating non-foods)

Question 9

pica

Answer 9

eating non-foods

Question 10

neophobia

Answer 10

fear of the new
- New and previously liked foods
- Decreases with age
○ 69% 2yo refuse to taste new foods
○ 29% 3yo
○ <1% 5yo
- 10-20 tastes needed before may ‘like’ food
- Exposure during weaning sets foundation
- BF and exposure (BF supports exposure and familiarity with flavour profiles)

Question 11

critical period in weaning

Answer 11

• Fewer exposures needed over weaning period
  ○ Birch et al., (1998): 1 exposure = 50% increase in intake in 4-7 month olds
  
  • More exposures needed after weaning
  • But not critical period because…
    ○ Older child/adult will accept novel food eventually
    ○ Continued cognitive development influences further acceptance
    ○ Information in healthiness, for example, an influence intake

Question 12

food preferences in childhood

Answer 12

• Children prefer
  ○ Sweeter tastes
  ○ Familiar foods
  ○ Greater post-indigestive feedback
  
  • Children dislike
    ○ Bitter tastes
    ○ Tastes associated with illness or treatment (e.g. cancer)
    ○ Less post-indigestive feedback

Question 13

how much to eat?

Answer 13

• Infants and young children very good at self-regulation
  
  • Early models based on homeostatic principles
  • Motivated to maintain absence of hunger
  • Eat until homeostasis is restored
  • Birch and Dysher (1986)
    ○ 2-5yo children
    ○ High or low energy preload snack; 40kcal vs 150kcal
    ○ Lunchtime energy intake measured
  • Compensation very accurate
  • More accurate than adults
  • Birch et al., (2003)
    ○ Eating in the absence if hunger (EAH) increases from 5-9 years
  • Rolls et al., (2000)
    ○ Macaroni cheese offered in different portion sizes
    ○ 2-3 year olds eat approximately same
    ○ 4-6 yo eat +60% if portion size doubled

Question 14

types of weaning

Answer 14

traditional and baby-led

Question 15

traditional weaning

Answer 15

○ Caregiver spoon feeding
○ Pureed –> small lumps –> larger lumps –> solids
○ Semi-prescribed order of introduction
○ May include baby jars
○ Caregivers select meals

Question 16

baby-led weaning

Answer 16

○ Self-feeding solid finger foods
○ No purees or infant specific foods
○ Same foods as family
○ More able to influence own food choice

Question 17

weaning method and child weight gain

Answer 17

• Townsend and Pitchford (2012)
  ○ Compared 52 spoon-fed (SF) and 54 baby-led-weaned (BLW) infants
  ○ Found:
  § Higher incidence of overweight/obesity in SF group
  § Higher incidence of underweight in BLW group
  § Significantly increased liking for carbs in BLW group
  § Carbs most preferred food of BLW group, sweet foods most preferred food of SF group

Question 18

why is there a correlation between weaning method and child weight gain?

Answer 18

• Type of food given:
  ○ SF given sweet foods more often e.g., pork and apple
  ○ SF learned preference for sweet foods likely influences
  preferences and unhealthy food choices in future
  ○ BLW: Post-ingestive feedback – when choose own foods, learn that carbs are more satiating = preference
  
  • Caregiver feeding practices
    ○ SF infants more likely to be pressured to eat; dictated by external cues (e.g., food left in the jar)
    ○ General differences in familial attitudes towards food
    ○ NB: findings cross-sectional

Question 19

problems with BLW

Answer 19

• Only effective if caregivers haver varied diet
  ○ Evidence some parents/caregivers don’t have appropriate diets; high in salt, sugar, saturated fat, yet low in energy density and folate (Rowan & Harris, 2012)
  
  • Rarely ready to self-feed before 6 months
    ○ If guidelines change to recommend earlier weaning, then BLW not as appropriate
  • Some evidence BLW infants consume less food and more milk
    ○ Could lead to nutritional deficiencies

Question 20

problems with SF weaning

Answer 20

• Prolonged duration of smooth foods – delays development of oral skills (Mason et al., 2005)
  
  • Less exposure to different textures = more food refusal later on (Northstone et al., 2001)
    ○ Best predictor of eating chopped carrots in 12- month-old is experiences with carrots in variety of forms / textures (Blossfeld et al., 2007)
  • Effect of exposure to textures does not transfer from processed baby food to homemade meals (Birch et al., 1998)

Question 21

how common is inappropriate feeding?

Answer 21

relatively common

Question 22

what is inapprpriate feeding driven by?

Answer 22

• Driven by inappropriate beliefs
  ○ Benefits to sleep
  ○ Belief hunger is main cause of distress
  
  • Some generational influences
    ○ Parents/grandparents
  • Confusion over guidelines

Question 23

risk factors for inappropriate feeding

Answer 23

• Wasser et al., (2011)
  ○ More common in certain populations
  § Mothers with depression, obesity
  § Low SES family
  § Non-breast-fed infants
  ○ Links to child temperament
  § Positive association between inappropriate feeding and both ‘activity level’ and ‘distress to limitations’
  § But, may be mediated by parent self-efficacy (Anzman-Frasca et al., 2013)

Question 24

how does inappropriate feeding link to obesity?

Answer 24

• Thompson and bentley (2013) - US study
  ○ 217 low SES, first-time mums in US Infant Care and Risk of Obesity Study
  ○ 78% of infants received age-inappropriate solids and liquids at 3 months old
  ○ 10% given fruit juice from 2 months of age
  ○ 25% drinking soft drinks by 18 months; 10 x higher than breast milk consumption!
  ○ Associated with higher mean daily intake of over 100 kcal and higher weight-for-length ratio
  • Ong et al. (2006) - UK study
    ○ Each 100-kcal excess per day at 4 months =
    § 46% increased odds of overweight at 3 years
    § 25% increased odds of overweight at 5 years
    ○ Why?
    § Clear excess in energy and protein
    § Changes in hypothalamus
    □ Rat studies (Bouret, 2012)
    § Learned preferences

Question 25

what anxieties are there around weaning?

Answer 25

• Infant Feeding Survey (2010) found 11% UK mothers of 1-year-olds reported experiencing difficulties with weaning
  ○ Portion size and eating enough
  ○ Dealing with food rejection
  ○ Offering enough variety
  ○ Seeking helpful advice
  
  • Clear gap in provision of weaning information and support to parents/caregivers

Question 26

where can people get help around weaning?

Answer 26

Child feeding guide - website, app, online training:
- Commercialisation of research knowledge
- Free for parents/caregivers
- Training courses for childcare staff and health professionals

Question 27

what are the 2 places where there are common feeding problems?

Answer 27

childrens behaviour
caregivers behaviour

Question 28

common feeding problems in childrens behaviour

Answer 28

• Food refusal
  
  • Rejection of bitter tastes
  • Unhealthy food preferences
  • Many common difficulties reflect natural developmental stages or learned behaviour

Question 29

common feeding problems in caregivers behaviour

Answer 29

• Pressure to eat
  
  • Food as a reward
  • Food to soothe
  • Restriction
  • Caregivers often rely on unfavourable practices that can undermine healthy eating behaviours

Question 30

what is food refusal characterised by?

Answer 30

1. Refusing new of previously liked foods
   2. Rejection of bitter tastes - especially vegetables
   3. Can generalise to same texture, colours, etc

Question 31

why does food refusal occur?

Answer 31

○ Neophobia/developing cognition/developmentally predictable

Question 32

common caregiver responses to food refusal

Answer 32

○ Pressure to eat
○ Food as a reward

Question 33

what does pressure to eat predict?

Answer 33

• Predicts ‘picky’ eating in adults (Batsell et al., 2002)
  ○ “Bad memories of school dinners still affect the eating habits of many adults, a survey suggests” (BBC poll of 2,000 Good Food Magazine readers)

Question 34

how does pressure to eat come about?

Answer 34

coercion and bribing

Question 35

concerns of pressure to eat

Answer 35

• Often out of concern
  ○ Linked to lower child weight (Ruzicka et al., 2021)
  ○ Unrealistic portion sizes?
  Ruzicka et al. (2021).

Question 36

study as evidence for pressure to eat reduces intake

Answer 36

• Galloway et al. (2006)
  ○ N = 27 preschoolers (3-5 yrs)
  ○ 2 conditions
  § Pressured to eat soup (“finish your soup please”)
  § Control
  ○ Parental questionnaire about whether they used pressure to eat
  ○ Pressure condition
  § Did not eat more soup
  § More negative comments about soup

Question 37

evidence that pressure to eat increases intake

Answer 37

• Orell-Valente et al., (2007)
  ○ 142 families of kindergartners (52% females)
  ○ Observed at dinnertime using a focused-narrative observational system
  ○ 85% parents tried to get children to eat more
  ○ 83% of children ate more than they might otherwise
  ○ 38% ate moderately to substantially more

Question 38

why might pressure to eat lead to decreased intake?

Answer 38

○ Fear response
○ Less liking, negative associations

Question 39

why might pressure to eat lead to increased intake?

Answer 39

○ Fear response
○ Over-ride internal fullness

Question 40

study for food as a reward

Answer 40

• “you’re not having ice cream until you’ve eaten your peas”
  ○ e.g., Birch et al. (1984). Eating as the ‘means’ activity in a contingency: effects on young children’s food preferences. Child Development, 55, 432–439.

Question 41

why might foods become less liked when a reward is offered?

Answer 41

negative associations

Question 42

why might foods become more liked when a reward is offered?

Answer 42

prize
desired

Question 43

studies as food to soothe

Answer 43

• Stifter et al., (2011)
  ○ 43 male infants/toddlers (3-34 months)
  ○ Questionnaires on use of food to soothe, parent feeding practices, parenting self-efficacy, child temperament
  ○ Weight and length taken
  • Blissett, Haycraft and Farrow (2010)
    ○ 25 children aged 3-5-years
    ○ Ate lunch to satiety
    ○ Allocated to control or negative mood condition
    ○ Children whose mothers used food to regulate emotions ate more cookies in the absence of hunger regardless of condition
    ○ Children whose mothers used food to regulate emotions ate more chocolate in the negative mood condition than in the control condition
    ○ Shows they have already learnt to deal with emotions using food

Question 44

use of food to soothe is associated with

Answer 44

○ Higher child BMI
○ More negative child temperament
○ Lower parenting self-efficacy

Question 45

what does the use of non-reward foods lead to?

Answer 45

increased liking

Question 46

can incentives work?

Answer 46

• Incentives can be effective at
  ○ Altering children’s food choices (Orrell-Valente et al., 2007)
  ○ Increasing children’s consumption of foods (Baer et al., 1987)
  
  • Significant, sustained increases in liking in children praised for repeated tasting of a vegetable over 12 days (Cooke et al., 2011)

Question 47

Holley, Haycraft and Farrow (2015)

Answer 47

• 115 parent/child pairs recruited from toddler groups
  
  • 2.5- to 4-year-olds
  • Each child assigned a target disliked vegetable based on parent rankings verified with a taste test
  • Experimental group parents: offered child target vegetable outside of a mealtime for 14 consecutive days
  • Control group: no offerings, just baseline and follow-up 5 minute free-eating test
  • Holley, Haycraft & Farrow (2015). ‘Why don’t you try it again?’ A comparison of parent led, home based interventions aimed at increasing children’s consumption of a disliked vegetable. Appetite, 87, 215-222.

results:
- Children’s consumption of a disliked / refused vegetable can be increased via a 14-day programme of offering and tasting with incentives and praise, plus parental modelling
- Although parental modelling may impact acceptance when combined with incentives, it does not seem to be sufficient as a solo method to achieve tastings
- Just seeing a parent eating it and saying it was nice wasn’t effective enough, they needed an incentive

Question 48

what is restriction characterised by?

Answer 48

1. Restricting access to desired foods/drinks
   
   2. Often high-calorie “treat” foods

Question 49

why does restriction occur?

Answer 49

○ Response to child weight / health concerns
Driven by child innate preferences

Question 50

common caregiver responses to restriction - types of restriction

Answer 50

○ Overt restriction (restriction that the child is aware of “can I have another one?” “No you can’t”
○ Inconsistent restriction (one day they get sweets after pudding, another day they don’t - gets confusing

Question 51

studies for over restriction

Answer 51

• Fisher and Birch (1999) 3-5y/o
  ○ Two snacks in daycare
  § Snack 1 available for full duration of snack time
  § Snack 2 only available for a limited duration
  ○ Snack 2
  § “I want it!”
  § Clapping when available
  § Pounding fists on table when access no longer available
  § Consumed more when available
• Birch et al. (2003). Learning to overeat: maternal use of restrictive feeding practices promotes girls’ eating in the absence of hunger. Am J Clinical Nutrition, 78(2), 215-20.
  ○ 197girls: tested at 5, 7 and 9 years
  ○ Girls eat lunch until full
  ○ Free access food/toy
  ○ Found restriction at 5 led to eating in the absence of hunger at 7 and 9
  § Especially if overweight

Question 52

why does restriction lead to increased intake?

Answer 52

prize
desired
want something cant have

Question 53

how does a caregiver restrict in a good way?

Answer 53

covertly

Question 54

factors motivating caregiver control

Answer 54

• Concern about child weight
  
  • Demographic factors
  • Sex of child/parent