NUTRITION – PREGNANCY

Helping Children Develop

Healthy Eating Habits
Maureen M. Black, PhD, Kristen M. Hurley, PhD

University of Maryland School of Medicine, USA

September 2013, 2e éd. rév.

Introduction

The first year of life is characterized by rapid developmental changes related to eating. As infants
gain truncal control, they progress from sucking liquids in a supine or semi- reclined position to
eating solid foods in a seated position. Oral motor skills progress from a basic suck-swallow
mechanism with breast milk or formula to a chew-swallow mechanism with semi-solids,
progressing to complex textures.1,2 As infants gain fine motor control, they progress from being
fed exclusively by others to at least partial self-feeding. Their diet extends from breast milk or
formula, through purees and specially prepared foods, to the family diet. By the end of the first
year of life, children can sit independently, can chew and swallow a range of textures, are learning
to feed themselves and are making the transition to the family diet and meal patterns.

As children transition to the family diet, recommendations address not only food, but also the
eating context. A variety of healthy foods promote diet quality, along with early and sustained
food acceptance. Data gathered on infants and young children 6 to 23 months of age across 11
countries have demonstrated a positive association between dietary variety and nutritional status.
3
Exposure to fruits and vegetables in infancy and toddlerhood have been associated with
acceptance of these foods at later ages.4-6

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Children’s eating patterns and food preferences are established early in life. When children refuse
nutritious foods such as fruits or vegetables, mealtimes can become stressful or confrontational,
and children may be denied both the nutrients they require and healthy, responsive interactions
with caregivers. Caregivers who are inexperienced or stressed, and those who have poor eating
habits themselves, may be most in need of assistance to facilitate healthy, nutritious mealtime
behaviour with their children.

Subject

Problems associated with eating occur in 25% to 45% of all children, particularly when children
are acquiring new skills and are challenged with new foods or mealtime expectations.7 For
example, infancy and toddlerhood are characterized by bids for autonomy and independence as
children strive to do things themselves. When these characteristics are applied to eating
behaviours, children may be neophobic (hesitant to try new foods) and insist on a limited
repertoire of foods,8 leading them to be described as picky eaters.

Most eating problems are temporary and easily resolved with little or no intervention. However,
eating problems that persist can undermine children’s growth, development, and relationships
with their caregivers, leading to long-term health and developmental problems.9 Children with
persistent eating problems whose caregivers do not seek professional advice until the problems
become severe, may be at risk for growth or behaviour problems.

Problems

Eating patterns have developmental, family and environmental influences. As children become
developmentally able to make the transition to family foods, their internal regulatory cues for
hunger and satiety may be overridden by familial and cultural patterns. At the family level,
children of caregivers who model healthy food intakes are likely to consume more fruits and
vegetables than children of caregiver who do not, whereas children of caregivers who model less
healthy, snack food intakes are likely to establish patterns of eating behaviours and food
preferences that include excess amounts of fat and sugar.10 At the environmental level, children’s
frequent exposure to fast-food and other restaurants has led to increased consumption of high-fat
foods, such as french fries, rather than more nutritious options, such as fruit and vegetables.11 In
addition, caregivers may not realize that many commercial products marketed for children, such
as sweetened drinks, may satisfy hunger or thirst, but provide minimal nutritional benefits.12

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National surveys have reported excessive caloric intakes during toddlerhood,13,14 and many
children continue to consume alarmingly low quantities of fruit and vegetables and essential
micronutrients.15 By elementary school, many children receive over half their beverage intake
from sweetened drinks,16 a pattern that undoubtedly begins during the toddler and preschool
years. These poor nutritional patterns (high fat, sugar and refined carbohydrates; sweetened
drinks; and limited fruit and vegetables) increase the likelihood of micronutrient deficiencies (e.g.,
Iron Deficiency Anemia) and excess weight gain in young children.17

Research Context

Eating is often studied through observational studies or caregiver reports of mealtime behaviour.
Some investigators rely on clinical samples of children with growth or eating problems, while
others recruit normative children.

Key Research Questions

Key questions include the progression of eating behaviours from infancy through toddlerhood,
methods children use to signal hunger and satiety, and why some children (the so-called “picky”
eaters) have selective food preferences. Key questions for caregivers and families are how to
promote healthy eating behaviours in young children, how to encourage children to eat healthy
food, and how to avoid problems in feeding and growth.

Recent Research Results

Attachment and eating

Healthy eating behaviour begins in infancy, as infants and their caregivers establish a partnership
in which they recognize and interpret both verbal and non-verbal communication signals from one
another. This reciprocal process forms a basis for the emotional bonding or attachment between
infants and caregivers that is essential to healthy social functioning.18 If there is a disruption in the
communication between children and caregivers, characterized by inconsistent, non-responsive
interactions, the attachment bond may not be secure, and eating may become an occasion for
unproductive, upsetting battles over food.

Infants who do not provide clear signals to their caregivers or do not respond to their caregivers’
efforts to help them establish predictable routines of eating, sleeping and playing are at risk for
regulatory problems that may include eating.9 Infants who are premature or ill may be less

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responsive than healthy full-term infants and less able to communicate hunger or satiety.
Caregivers who do not recognize their infants’ satiety cues may overfeed them, causing infants to
associate feelings of satiety with frustration and conflict.

The caregiver-child context of feeding

Variability in the caregiver-child feeding context is related to children’s eating behaviour and
growth.19 The dimensions of parental structure and nurturance, which incorporate parents’
perceptions of their child’s behaviour, have been applied to the feeding context (Figure 1).20,21,22
Responsive feeding reflects a reciprocal pattern in which caregivers provide guidance and
developmentally appropriate responses to their child’s signals of hunger and satiety.
Unresponsive feeding is marked by a lack of reciprocity between the caregiver and child, often
characterized by the caregiver taking excessive control of the feeding context (forcing/pressuring
or restricting food intake), the child controlling the feeding context (e.g., demanding a limited
repertoire of food, indulgent feeding), or the caregiver ignoring the child’s signals or failing to
establish mealtime routines (uninvolved feeding).23,24

Figure 1. The Caregiver-Child Feeding Context: Patterns of Parenting and Feeding

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A controlling feeding style, high in structure and low in nurturance, represents caregivers who use
forceful or restrictive strategies to control mealtimes. Controlling feeding is embedded in an
overall authoritarian pattern of parenting and may include over-stimulating behaviours, such as
speaking loudly, forcing foods or otherwise overpowering the child.27 Controlling caregivers may
override their child’s internal regulatory cues for hunger and satiety.28 The innate capacity that
infants have to self-regulate their energy intake declines during early childhood in response to
family and cultural patterns.29 A responsive feeding style, high in nurturance and structure, a
derivative of authoritative parenting, represents caregivers who form a relationship with their
child that involves clear demands and mutual interpretation of signals and bids for mealtime
interaction. Responsive feeding is characterized by interactions that are prompt, contingent on
the child’s behaviour and developmentally appropriate with an easy give-and-take.22,25,26

An indulgent feeding style, high in nurturance and low in structure, is embedded in an overall
indulgent style of parenting, and occurs when caregivers allow children to make decisions around
meals, such as when and what they will eat.23 Without parental guidelines, children are likely to be
attracted to high salt/high sugar foods, rather than to a more balanced variety including
vegetables.23 Thus, an indulgent feeding style may be problematic, given infants’ genetic
predispositions to prefer sweet and salty tastes.30 Children of caregivers who display an indulgent
feeding style are often heavier than children of caregivers who use non-indulgent feeding styles.24

An uninvolved feeding style, low in both nurturance and structure, often represents caregivers
who have limited knowledge and involvement in their child’s mealtime behaviour.23 Uninvolved
child feeding styles may be characterized by little or no active physical help or verbalization
during feeding, lack of reciprocity between the caregiver and child, a negative feeding
environment and a lack of feeding structure or routine. Uninvolved feeders often ignore both child
feeding recommendations and their toddler’s cues of hunger and satiety and may be unaware of
what or when their toddler is eating. Egeland and Sroufe31 found that children of uninvolved or
psychologically unavailable caregivers were more likely to be anxiously attached when compared
with children of available caregivers. An uninvolved feeding style is embedded in an overall
uninvolved style of parenting.23

Several recent systematic reviews report associations between parental feeding control and infant
and early child weight gain and/or weight status.24,32,33 Controlling feeding has been associated with
increased weight gain (e.g., children of caregivers who use restrictive feeding practices tend to
overeat)34 and to decreased weight gain (e.g., children who are pressured to eat more, do not).35

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However, the cross-sectional design of most studies, along with a tendency to rely exclusively on
caregiver behaviour, rather than consider the reciprocal nature of feeding interactions, has
hindered the understanding of caregiver-child feeding interactions. A recent randomized
controlled trial among infants in Australia found that providing anticipatory guidance regarding
infant feeding behaviour led to healthier weight gain and higher rates of self-reported responsive
feeding behaviour.36 Additional trials are needed to better understand strategies to promote
healthy feeding interactions and healthy growth.

Food preferences

Children who are raised with caregivers who model healthy eating behaviours, such as a diet rich
in fruit and vegetables, establish food preferences that include fruit and vegetables.4

Food preferences are also influenced by associated conditions. Children are likely to avoid food
that has been associated with unpleasant physical symptoms, such as nausea or pain. They may
also avoid food that has been associated with the anxiety or distress that often occurs during
meals characterized by arguments and confrontations.

Children also accept or reject food based on qualities of the food, such as taste, texture, smell,
temperature or appearance, as well as environmental factors, such as the setting, the presence of
others and the anticipated consequences of eating or not eating. For example, consequences of
eating may include relief from hunger, participation in a social function or attention from
caregivers. Consequences of not eating may include additional time to play, becoming the focus
of attention or getting snack food instead of the regular meal.

Increasing familiarity with the taste of a food increases the likelihood of acceptance.37,38 Caregivers
can facilitate the introduction of new foods by pairing the new food with preferred food and
presenting the new food repeatedly until it is no longer “new.”

Conclusions

Eating patterns are established early in life in response to internal regulatory cues, caregiver-child
interactions, mealtimes routines, foods offered and modeling from family members. Exposing
children to fruits and vegetables early in life establishes a pattern of fruit and vegetable
preference and consumption throughout life. Research is needed to investigate the individual,
interactive and environmental determinants of the caregiver-child feeding context, relationships

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between responsive/unresponsive feeding and children’s eating behaviour and weight gain and
population-specific validated tools to measure responsive/unresponsive feeding.24

Early childhood eating behaviours are heavily influenced by caregivers and are learned through
early experiences with food and eating. Education and support provided by health professionals
(i.e., public health nurses, family physicians and pediatricians) and nutrition programs need to be
strengthened to ensure that caregivers have the facilities needed to address issues of eating
behaviours during childhood.

Caregivers should eat with children so modelling can occur and mealtimes are viewed as pleasant
social occasions. Eating together lets children watch caregivers try new foods and helps children
and caregivers communicate hunger and satiety, as well as enjoyment of specific foods.39

Caregivers control both the food that is offered and the mealtime atmosphere. Their “job” is to
ensure that children are offered healthy food on a predictable schedule in a pleasant setting.39 By
developing mealtime routines, caregivers help children learn to anticipate when they will eat.
Children learn that feelings of hunger are soon relieved and there is no need to feel anxious or
irritable. Children should not graze or eat throughout the day, so they develop an expectation and
an appetite around mealtime.39

Mealtimes should be pleasant and family-oriented, with family members eating together and
sharing the events of the day. When mealtimes are too brief (less than 10 minutes), children may
not have enough time to eat, particularly when they are acquiring self-feeding skills and may eat
slowly. Alternatively, sitting for more than 20 or 30 minutes is often difficult for a child and
mealtimes may become aversive.

When meals are characterized by distractions from television, family arguments or competing
activities, children may have difficulty focusing on eating. Caregivers should separate mealtime
from playtime and avoid using toys, games, or television to distract the child during mealtime.
Child-oriented equipment, such as highchairs, bibs and small utensils, may facilitate eating and
enable children to acquire the skills of self-feeding.

Implications

Implications can be directed to environmental, family and individual levels. At the environmental
level, encouraging fast-food and other restaurants to also provide healthy, palatable food options

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that are appealing to young children may reduce some of the feeding problems that occur when
children are repeatedly exposed to high-fat foods, such as french fries, rather than to nutritious
options, such as fruit and vegetables. At the family level, guidelines for children’s nutrition should
include information on their nutritional needs and on strategies to promote healthy eating
behaviour, including recognizing children’s signals of hunger and satiety and use of appropriate
feeding interactions, allocating time for meals, scheduling meals at relatively consistent times,
promoting new foods through modelling and avoiding stress and conflict during meals. At the
individual level, programs that help children develop healthy eating patterns by eating nutritious
foods and eating to satisfy hunger, rather than to satisfy emotional needs, may prevent
subsequent health and developmental problems.40

References

1. Bosma J. Development and impairments of feeding in infancy and childhood. In: Groher ME, ed. Dysphagia: Diagnosis and
management. 3rd ed. Boston, MA: Butterworth-Heinemann; 1997:131-138.

2. Morris SE. Development of oral motor skills in the neurologically impaired child receiving non-oral feedings Dysphagia
1989;3:135-154.

3. Arimond M, Ruel MT. Dietary diversity is associated with child nutritional status: Evidence from 11 demographic and health
surveys. The Journal of Nutrition 2004;134:2579-2585.

4. Skinner JD, Carruth BR, Bounds W, Ziegler P, Reidy K. Do food-related experiences in the first 2 years of life predict dietary
variety in school-aged children? Journal of Nutrition Education and Behavior 2002;34(6):310-315.

5. Schwartz C, Scholtens PA, Lalanne A, Weenen H, Nicklaus S. Development of healthy eating habits early in life. Review of
recent evidence and selected guidelines. Appetite. 2011;57(3):796-807.

6. Mennella JA, Nicklaus S, Jagolino AL, Yourshaw LM. Variety is the spice of life: strategies for promoting fruit and vegetable
acceptance during infancy. Physiol Behav. 2008;22;94(1):29-38.

7. Linscheid TR, Budd KS, Rasnake LK. Pediatric feeding disorders. In: Roberts MC, ed. Handbook of pediatric psychology. New
York, NY: Guilford Press; 2003:481-498.

8. Birch LL, McPhee L, Shoba BC, Pirok E, Steinberg L. What kind of exposure reduces children's food neophobia? Looking vs
tasting. Appetite 1987;9(3):171-178.

9. Keren M, Feldman R, Tyano S. Diagnoses and interactive patterns of infants referred to a community-based infant mental
health clinic. Journal of the American Academy of Child & Adolescent Psychiatry 2001;40(1):27-35.

10. Palfreyman Z, Haycraft E, Meyer C. Development of the Parental Modeling of Eating Behaviours Scale (PARM): links with
food intake among children and their mothers. Maternal and Child Nutrition. 2012 [Epub ahead of print].

11. Zoumas-Morse C, Rock CL, Sobo EJ, Neuhouser ML. Children’s patterns of macronutrient intake and associations with
restaurant and home eating. Journal of the American Dietetic Association 2001;101(8):923-925.

12. Smith MM, Lifshitz F. Excess fruit juice consumption as a contributing factor in nonorganic failure to thrive. Pediatrics
1994;93(3):438-443.

13. Ponza M, Devaney B, Ziegler P, Reidy K, Squatrito C. Nutrient intakes and food choices of infants and toddlers participating
in WIC. Journal of the American Dietetic Association 2004;104(1 Suppl 1):71-79.

©2013-2023 CEECD | NUTRITION – PREGNANCY 8

 14. Devaney B, Kalb L, Briefel R, Zavitsky-Novak T, Clusen N, Ziegler P. Feeding infants and toddlers study: overview of the
study design. Journal of the American Dietetic Association 2004;104(1 Suppl 1):8-13.

15. Picciano MF, Smiciklas-Wright H, Birch LL, Mitchell DC, Murray-Kolb L, McConahy KL. Nutritional guidance is needed during
dietary transition in early childhood. Pediatrics 2000;106(1):109-114.

16. Cullen KW, Ash DM, Warneke C, de Moor C. Intake of soft drinks, fruit-flavored beverages, and fruits and vegetables by
children in grades 4 through 6. American Journal of Public Health 2002;92(9):1475-1477.

17. Brotanek JM, Gosz J, Weitzman M, Flores G. Secular trends in the prevalence of iron deficiency among US toddlers, 1976-
2002. Archives of Pediatrics & Adolescent Medicine 2008;162:374-81.

18. Ainsworth MDS, Blehar MC, Waters E, Wall S. Patterns of attachment: A psychological study of the strange situation. New
York: Psychology Press, 1978.

19. Rhee K. Childhood overweight and the relationship between parent behaviors, parenting style, and family functioning. The
Annals of the American Academy of Political and Social Science 2008;615:11–37.

20. Baumrind D. Rearing competent children In: Damon W, ed. Child development today and tomorrow. San-Francisco, CA:
Jossey-Bass Publishers; 1989:349-378.

21. Maccoby EE, Martin J. Socialization in the context of the family: parent-child interaction. In: Hetherington EM, ed. Handbook
of child psychology: Socialization, personality, and social development. Vol 4. New York, NY: John Wiley; 1983:1-101.

22. Black MM & Aboud FE. Responsive feeding is embedded in a theoretical framework of responsive parenting. Journal of
Nutrition 2011;141(3):490-4.

23. Hughes SO, Power TG, Fisher JO, Mueller S, Nicklas TA. Revisiting a neglected construct: Parenting styles in a child-feeding
context. Appetite 2005;44(1):83-92.

24. Hurley KM, Cross MB, Hughes SO. A systematic review of responsive feeding and child obesity in high-income countries.
Journal of Nutrition 2011;141:495-501.

25. Leyendecker B, Lamb ME, Scholmerich A, Fricke DM. Context as moderators of observed interactions: A study of Costa
Rican mothers and infants from differing socioeconomic backgrounds. International Journal of Behavioural Development
1997;21(1):15-24.

26. Kivijarvi M, Voeten MJM, Niemela P, Raiha H, Lertola K, Piha J. Maternal sensitivity behaviour and infant behaviour in early
interaction. Infant Mental Health Journal 2001;22(6):627-640.

27. Beebe B, Lachman F. Infant research and adult treatment: Co-constructing interactions. Hillsdale, NJ: The Analytic Press;
2002.

28. Birch LL, Fisher JO. Mothers' child-feeding practices influence daughters' eating and weight. American Journal of Clinical
Nutrition 2000;71(5):1054-1061

29. Birch LL, Johnson SL, Andresen G, Peters JC, Schulte MC. The variability of young children's energy intake. New England
Journal of Medicine 1991;324(4):232-235.

30. Birch LL. Development of food preferences. Annual Review of Nutrition 1999;19:41-62.

31. Egeland B, Sroufe LA. Attachment and early maltreatment. Child Development 1981;52(1):44-52.

32. DiSantis KI, Hodges EA, Johnson SL, Fisher JO. The role of responsive feeding in overweight during infancy and toddlerhood:
a systematic review. International Journal of Obesity 2011;35:480-92.

33. Faith MS, Scanlon KS, Birch LL, Francis LA, Sherry B. Parent-child feeding strategies and their relationships to child eating
and weight status. Obesity Research 2004;12(11):1711-1722.

34. Birch LL, Fisher JO, Davison KK. Learning to overeat: maternal use of restrictive feeding practices promotes girls' eating in
the absence of hunger. American Journal of Clinical Nutrition 2003;78(2):215-220.

©2013-2023 CEECD | NUTRITION – PREGNANCY 9

 35. Fisher JO, Mitchell DC, Smiciklas-Wright H, Birch LL. Parental influences on young girls' fruit and vegetable, micronutrient,
and fat intakes. Journal of the American Dietetic Association 2002;102(1):58-64.

36. Daniels LA, Mallan KM, Battistutta D, Nicholson JM, Perry R, Magarey A. Evaluation of an intervention to promote protective
infant feeding practices to prevent childhood obesity: outcomes of the NOURISH RCT at 14 months of age and 6 months
post the first of two intervention modules. International Journal of Obesity (Lond). 2012 Oct;36(10):1292-8.

37. Birch LL. Children’s preferences for high-fat foods. Nutrition Reviews 1992;50(9):249-255.

38. Birch LL, Marlin DW. I don’t like it; I never tried it: effects of exposure on two-year old children’s food preferences. Appetite
1982;3(4):353-360.

39. Satter E. Child of mine: Feeding with love and good sense. Palo Alto, CA: Bull Publishing; 2000.

40. Black MM, Cureton LA, Berenson-Howard J. Behaviour problems in feeding: Individual, family, and cultural influences. In:
Kessler DB, Dawson P, eds. Failure to thrive and pediatric undernutrition: A transdisciplinary approach. Baltimore, Md: Paul
H. Brookes Publishing Co.; 1999:151-169.

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