210 Black^3,000 infants and toddlers in the USA, by 7–8
months of age, 96% of children can grasp food
with their hands and 77% can remove food from
a spoon with their lips with little spilling; by 15–
18 months, 64% of children can self-feed with a
spoon with little spilling [8]. In addition to the
maturational changes that inf luence feeding be-
havior, caregivers play central roles in socializing
children into feeding routines and managing
their feeding behavior.
Caregiver Feeding Practices
Feeding practices are the behaviors that caregiv-
ers use to feed their children and help them gain
feeding skills. Caregiver feeding practices are in-
fluenced by cultural, environmental, and person-
al factors, along with caregivers’ perceptions of
their child’s size, appetite, and temperament. In
some cultures, children are fed separately from
the family, while in others, they eat together and
thus may model feeding behaviors from parents
and siblings. In some households, mothers have
limited time to spend feeding their children [9].
Caregivers of children with high rates of food re-
fusal report depressive symptoms. Maternal de-
pression has been associated with unresponsive
feeding practices through caregiver report [10]
and observation [11] , including verbal and physi-
cal pressure along with using incentives (bargain-
ing) to get their child to eat. These strategies may
override children’s internal regulatory cues [12]
and lead to overemotionalizing food and eating,
thus increasing the risk of children using feeding
behavior as a tool for manipulation. In addition
to depressive symptoms, caregivers with poor
feeding behavior themselves, such as frequent in-
take of snacks and sugar-sweetened beverages, in-
consistent meal times, and use of food as rewards,
increase the likelihood of their children’s feeding
problems. Caregivers who are concerned about
their child’s feeding behavior and growth have
been observed to use negative, coercive strategies
to promote eating [3] , along with permissive
strategies such as making food available through-
out the day or providing favorite foods (e.g., sweet
or salty snacks) with little regard to quality. These
strategies are likely to undermine children’s nor-
mal appetite development, increasing mealtime
stress as children hold out for snacks. Caregivers
also use food to manage children’s behavior, es-
pecially children who are perceived to be temper-
amentally difficult. This strategy has been associ-
ated with overeating among preschoolers [13].
Early in life, children learn that food refusal can
be a powerful strategy that attracts the caregiver’s
attention and may lead to increased access to
snacks and favorite foods.
Responsive feeding is a strategy based on both
control and nurturance. Caregivers provide
mealtime structure by selecting the food, the
timing, and the context in which feeding takes
place ( fig. 1 ). They also respond to children’s sig-
nals of hunger and satiety promptly, and with de-
velopmentally appropriate and nurturing feeding
practices [14]. Responsive feeding acknowledges
children’s feelings and allows them to determine
how much they eat, while the caregiver decides
what is offered and when. Embedded within the
domain of responsive parenting, responsive feed-
ing emphasizes the interactive nature of feeding,
whereby caregivers set guidelines but their reac-
tions are gaged to the signals they read from their
children, ideally resulting in a respectful give-
and-take (serve-and-return) around feeding, in
turn resulting in healthy weight gain.Screening, Recommendations, and
InterventionsSystematic strategies are available to screen
for children’s feeding problems, such as the Be-
havioral Pediatrics Feeding Assessment Scale
(BPFAS) [15] , a 35-item scale that asks caregiv-
ers to respond to the frequency of child and
caregiver feeding behaviors along with an indi-Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 209–213
DOI: 10.1159/000367875