Child Nutrition PDF

Child nutrition
Updated: September 2013
Topic Editor :
Myles S. Faith, PhD, University of North Carolina at Chapel Hill, USA
Table of contents
Synthesis 3
Feeding skill, Appetite and Feeding Behaviours of Infants and Young Children and Their 5
Impact on Growth and Psychosocial Development
MARIA RAMSAY, PHD, SEPTEMBER 2013
Feeding Behaviour of Infants and Young Children and Its Impact on Child Psychosocial 11
and Emotional Development
YI HUI LIU, MD MPH, MARTIN T. STEIN, MD, SEPTEMBER 2013
Helping Children Develop Healthy Eating Habits 16

MAUREEN M. BLACK, PHD, KRISTEN M. HURLEY, PHD, SEPTEMBER 2013
Assessment and Treatment of Pediatric Feeding Disorders 23

SUZANNE M. MILNES, PHD, CATHLEEN C. PIAZZA, PHD, TAMMY CARROLL, PHD, SEPTEMBER 2013
Genetic Influences on Child Eating Behaviour 27

CLARE LLEWELLYN, PHD, JANE WARDLE, PHD, SEPTEMBER 2013
Television (TV) and TV Advertisement Influences on Children’s Eating Behaviour 33

CHRISA ARCAN, PHD, MEG BRUENING, MPH, RD, MARY STORY, PHD, SEPTEMBER 2013
Eating Behaviour in Studies of Child Growth, Development and Health – Measure 40

Precisely, Early and in Context: Commentary on Ramsay, Liu & Stein, Black & Hurley,
Milnes, Piazza & Carrol, Llewellyn & Wardle, and Arcan, Bruening and Story
MYLES S. FAITH, PHD, SEPTEMBER 2013
©2013-2017 CEECD / SKC-ECD | CHILD NUTRITION 2

Synthesis
How important is it?
Oral motor skills such as sucking and chewing develop rapidly during the first year, allowing young children to
discover an increasing number of foods and textures. Refinements in fine motor skills also allow infants to
develop more autonomy in regards to feeding, and by the end of the second year, most children have acquired
good feeding skills. At this age, children become increasingly influenced by external signals such as family,
friends, and society, to dictate their hunger.
Feeding problems are common, and touch approximately 25% to 50% of young children. These problems are
usually minor and temporary. They tend to be seen when children are exposed to new foods or events during
mealtime, or when they are trying to master a new feeding skill. However, 1% to 2%of children experience
chronic feeding problems, including overeating, malnutrition, problematic behaviours during meals and atypical
eating choices. These problems are especially common in children born prematurely, and those with
developmental disabilities. Eating problems can be highly stressful for parents and can result in a strained
parent-child relationship.
What do we know?
Early feeding experiences can have long-lasting consequences on eating habits and food preferences later on
in life. A healthy diet consisting of ample fruits and vegetables in the first two years may increase future
preferences for healthy food. In contrast, unhealthy habits, such as favoring food that is high in fat and sugar
tend to persist over time.
Feeding problems are associated with a number of poor developmental, psychological and health outcomes.
For instance, children who overeat are more likely to develop medical conditions and potential psychological
issues, whereas insufficient calorie intake can result in stunted growth.
Several factors play a role in the development of feeding problems. Feeding difficulties are likely to emerge
when feeding has been paired with a painful or unpleasant experience that the child comes to associate with
mealtime. Temperament traits such as the inability to self-regulate and to communicate one’s hunger level can
make feeding routine challenging. Similarly, a genetic predisposition for big or small appetite can increase the
likelihood of feeding problems.
Parents play a central role during feeding throughout the early years. Breastfeeding, for instance, not only
protects against contagious diseases, but also allows infants to develop the ability to control their own calorie
intake, an important healthy eating habit. Parents also contribute positively to their child’s feeding by modeling
healthy eating habits and making mealtimes enjoyable.
When feeding problems emerge, mealtimes can become loaded with anxiety and frustration for both children

and parents. Misreading the child’s signals can further aggravate problematic behaviours. Strategies to
encourage eating such as punishment, distractions, and toys can work temporarily, but they tend to worsen
problems over time. The most effective approach is responsive feeding, where reciprocal interactions during
meals are based on the child’s signals, and are age-appropriate.
At a larger scale, culture also contributes to feeding experiences by its influence on feeding choices, behaviours
and exposure to different types of food. For instance, children’s exposure to advertisements of unhealthy food is
related to their preference for this type of food, and this is especially problematic in the African American and
Hispanic American communities.
What can be done?
Given that feeding problems most often originate from multiple causes, multidisciplinary approaches that
consider cultural and temperamental differences are strongly recommended. Although not all children respond
equally well to interventions, several strategies have been successful at promoting a healthy diet, starting with
those involving parents. Parents can help reduce overeating by cooking smaller quantity of food per meal,
thereby limiting access to oversized portion, and by encouraging their children to slow down their eating speed
by putting their utensils down after each bite. Parents can also encourage healthy habits by discussing feelings
of satiety, modelling healthy eating habits, and limiting the amount of television watching to 1 to 2 hours a day
of quality programming, and only in children over 2 years. Parents who discuss the content of advertisement
messages and who regulate the type of food their young child eats are likely to be successful at discouraging
unhealthy habits.
In cases of insufficient calorie intake, medications that increase appetite have been shown to positively affect
weight gain, and can make psychosocial intervention more efficient. The acceptance of new foods can also be
encouraged by pairing the new food with a preferred food until the new food becomes familiar. To make
mealtimes pleasant, children should be given enough time to eat (between 10 to 30 minutes) and proper
equipment (ex., highchairs, and small utensils). Feeding is an intricate skill that takes time to develop. Parents
and professionals can be about the specific impact of problematic feeding behaviour and motivation.
Information about healthy habits can be transmitted to parents during regular health check-ups.
At the policy level, several steps can be undertaken to reduce accessibility to unhealthy foods. These include
the elimination of vending machines in schools, stricter advertising and menu regulations, quotas assigned to
the number of fast food restaurants and changes in supermarket layouts.

Feeding skill, Appetite and Feeding
Behaviours of Infants and Young Children
and Their Impact on Growth and
Psychosocial Development
Maria Ramsay, PhD
McGill University, Canada
September 2013, Rev. ed.
Introduction
Feeding, like other sensorimotor skills, is a developmental skill that matures during the first two years of life. It is
a highly complex sensorimotor process with developmental stages based on neurological maturation and
1
experiential learning. However, feeding, unlike other sensori-motor skills, is heavily reliant on internal incentive
or motivation to initiate ingestion, and is essential for survival of the newborn. Thus, the act of feeding is highly
charged emotionally for the mother, whose primary responsibility, as viewed by the family, society and culture
around her, is to ensure the early growth and well being of her child. Therefore, from the very beginning the
2
mother-infant feeding relationship is influenced by physiologic as well as interactional forces at multiple levels.
Subject
When feeding skills are intact and appetite is robust, feeding times, and later on, mealtimes are a source of
pleasant socialisation resulting in adequate nutrient intake and good growth. Demanding food at regular
intervals, sucking, eating and drinking with good rhythm, trying new food tastes or textures, and expressing
satisfaction at the end of feeding are all considered good feeding behaviours by family and society. These pro-
feeding behaviours invite praise and positive feeding interactions and thus reinforce the feeling of self-mastery
in the young child and promote continued food acceptance and independent feeding behaviours.
However, when feeding skills are impaired (e.g.: poor oral-motor skills, taste and texture sensitivities) and or
poor appetite (inadequate hunger), they manifest themselves in problematic feeding behaviours such as not
3-7
signalling hunger, sucking or eating excessively slowly, gagging, and not bringing food to the mouth. In
addition, associative conditioning to painful gastrointestinal cues is particularly powerful in young infants and
8,9
this conditioning often manifests itself in problematic feeding behaviours. Temperamental characteristics and
10,11
regulatory capacities of the infant may further modulate feeding behaviours. Maternal attempts at increasing
her infant’s nutrient intake by feeding more frequently or longer duration tend to result in stressful feeding
12
experiences for both. While these efforts may work well initially for maintaining good weight gain, they tend to
2,13-15
become ineffective and maladjusted mealtime interactions and behavioural mismanagement prevail.

Maternal and family characteristics and societal expectations about the size of the young child and the type of
16,17
food eaten further influence an already stressful feeding relationship.
Problems
Feeding difficulties are one of the most common developmental disturbances in otherwise healthy infants and
young children, often resulting in poor growth. Although an estimated 25%- 50% of children experience
18,19
transient feeding problems under two years of age, most feeding issues resolve by the end of early
childhood. However, an estimated 3-10% of children present with more severe forms of feeding problems which
20
put children at risk for impaired growth, chronic illnesses and behavioural developmental problems. As well, a
large percentage of children with special needs, children with developmental disabilities and children born
prematurely have severe and chronic feeding problems where families need support in resolving the feeding
21-23
issues. At the clinical level, the mother (and her paediatrician) is often not aware of the underlying reasons
for problematic feeding behaviours. Thus, the mother’s reactions to a poor feeder may be exposed to covert or
4
overt family criticism, which often lead to internal doubt about her own ability to nurture. At the policy level,
there is a lack of education of professionals and young parents about feeding as a highly complex
developmental skill, motivated by hunger and conditioned by parental reactions. Furthermore, professionals are
still not trained to recognize that when either feeding skills or motivation or both are impaired, problematic
feeding behaviours, stressed mealtime interactions and family conflicts are likely to result.
Research Context
Earlier cross sectional clinical studies examined the relationship between feeding difficulties and attachment,
24 24-30
maternal characteristics, family dynamics and feeding practices. These studies were conducted
prospectively, that is, after the children were diagnosed with poor growth. Several observational studies focused
31,32
on feeding interactions and problematic feeding behaviours. The development of feeding and patterns of
33-36
food acceptance have been studied by numerous psychologists. More recently, few researchers started to
focus on possible pathophysiology (heart rate variability, hormonal balance) of poor growth and problematic
37-39
feeding behaviours. Other studies were conducted in the context of primarily behavioural interventions for
40-43
problematic feeding behaviours in medically ill and very premature infants.
Key Research Questions
The extensive research in the area of feeding problems and poor growth can be divided along the following
three research questions:
1. How do maternal (family) characteristics (cognitive abilities, personality disorders, psychological status
and early attachment history) influence feeding behaviours and growth?
2. How do infant characteristics (feeding skills, appetite, temperament and other physiological
characteristics) influence feeding behaviours, mealtime interactions and growth?
3. How effective are behavioural and other forms of intervention for severe problematic feeding behaviours
in medically ill infants?

Recent Research Results
Only questions 2 and 3 will be summarised here. With a focus on infant characteristics, studies have shown that
feeding problems often co-occur with sleeping and behavioural disturbances (irritability, poor self-calming and
intolerance to change), suggesting that these are symptoms of a common underlying constitutional “regulatory
44,45
disorder” in infants and young children. In a large whole-population survey of children’s growth and
development, a significant portion (36%) of the 47 children identified with failure to thrive at one year of age
were found to have oral motor difficulties, suggesting that these children were biologically more vulnerable to
46
poor eating from birth. Another study showed that young infants with gastroesophageal reflux were
47
significantly more likely to have delay in their feeding skills and readiness behaviour for solids than controls. In
a prospective study of a group of healthy term infants (n=330), infants with inefficient sucking, as measured by
tracings on a polygraph, at one week and two months were significantly more likely to have mothers with
14
greater effort at feeding than infants with efficient sucking.
A number of studies have shown that children under 3 to 4 years of age eat primarily in response to appetite or
hunger cues, whereas older children’s eating are influenced by a variety of environmental (extra food available)
48,49
and social factors. As well, children with poor growth were observed to refuse offered food more often and
50
fed themselves significantly less often than controls. In terms of the third question, the literature reflects the
reality that presently we are better at identifying factors contributing to feeding problems at any level of severity
28,51,52
than treating them. Treating feeding problems at the primary or secondary level, while desirable, is not
53
always available for parents. Treating feeding disorders associated with severe medical illnesses,
developmental disabilities and gavage feedings requires the collaboration of multidisciplinary teams for
54-59
successful outcome. Lastly, studies have shown that appetite stimulating medications result in good weight
60-62
gain, and thus making intervention more efficacious.
Conclusions
Understanding feeding behaviours requires the knowledge of feeding as a developmental skill that matures
over time and is reliant on hunger (appetite) cues and experiential learning. Whereas feeding skills are well
established by two years of age, hunger cues shift from primarily internal to external (family, school and
societal) control only by 4-5 years. Thus, although initially problematic feeding behaviours tend to be reactions
to internal cues, these behaviours can become conditioned to external (coaxing parents) and societal cues.
Medical illnesses, prematurity and developmental disorders further interfere with the development of normal
feeding behaviours.
63-65
In order to help identify feeding problem, a number of feeding scales have been devised, but rarely used for
assessment or treatment outcome. Yet, early behavioural intervention can play an important role in normalizing
feeding behaviours and mealtime interactions, which in turn help promote independence and other self-help
skills in the child. Most recently, an easy and short screening tool was developed for detecting problematic
66
feeding behaviours in primary care offices, allowing early referral to appropriate feeding clinics.
Implications for Policy and Services
The major findings from this updated summary continue to be that the physiological make up of the infant,

medical illnesses, developmental disabilities and parental responses all play an important role in the dynamic
relationship in which problematic feeding behaviours develop. This finding has several implications for policy
and services in the area of impaired feeding behaviours and poor growth. The implications for policy and
services include:
1. At the primary care level, the use of easy to administer feeding scales for earlier detection and thus,
treatment of feeding problems should be advocated by paediatric and other primary care professionals’
associations.
2. The creation of multidisciplinary feeding clinics with the mandate of addressing feeding disorders should
be mandated in major hospital settings. These feeding programs need to be easily accessible to parents,
where effective behavioural intervention and preventive strategies may be implemented in the early
stages of reported difficult feeding behaviours.
3. The training of experts in the field of feeding disorders, which should include training in the behavioural,
developmental and interactional components of feeding at college and university levels should be
advocated.
4. Further research into treatment outcomes for children with feeding disorders need to be strongly
encouraged.
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Feeding Behaviour of Infants and Young
Children and Its Impact on Child
Psychosocial and Emotional Development
Yi Hui Liu, MD MPH, Martin T. Stein, MD
University of California San Diego, USA
September 2013, 2nd ed.
Introduction
Feeding is a primary event in the life of an infant and young child. It is the focus of attention for parents and
other caregivers, and a source of social interaction through verbal and non-verbal communication. The eating
experience provides not only sustenance but also an opportunity for learning. It affects not only children’s
physical growth and health but also their psychosocial and emotional development. The feeding relationship is
affected by culture, health status and temperament.
Subject
The essential component of feeding behaviour in young children is the relationship between the child and the
primary caregiver. The first three years of life are a particular challenge because a child’s feeding abilities and
needs change with motor, cognitive and social development. In the first stage (birth to three months) of self-
regulation and organization, the child integrates experiences of hunger and satiety to develop regular feeding
patterns. In the second stage (three to seven months), the infant and parent form an attachment that allows
them to communicate with each other and the infant develops basic trust and self-soothing behaviours. In the
third stage (six to 36 months), the child gradually “separates” emotionally from the parent and discovers a
sense of independence or autonomy, making use of developing motor and language skills to control the
environment and establish independent feeding.
With participation in family meals, the social component of feeding expands. The child begins to mimic eating
choices, patterns and behaviours modelled by family members. The structure of family meals sets limits for the
child as he or she achieves independent feeding skills. The accessibility of particular foods, modelling, media
exposure and feeding interactions shape a child’s eating behaviour and food preferences.
The caregiver’s behaviours and the child’s temperament influence the feeding relationship. The parent who
allows her infant to determine timing, amount and pacing of a meal helps her infant develop self-regulation and
secure attachment. The parent who allows her toddler to explore the environment while providing structure and
appropriate limits helps her child develop motor and social skills. The effective parent adjusts and responds
appropriately to her child’s temperament — the child’s emotional reactivity, adaptability and response to
change. Temperament can affect how a child approaches and responds to new foods and to a parent’s feeding

patterns.
Culture may significantly influence the feeding experience. It may determine not only the choice of infant
feeding (breast milk or formula) but also associated behaviours (co-sleeping is linked to prolonged
breastfeeding), the length of feeding method (later weaning in developing countries versus earlier weaning for
working mothers in developed countries), and exposure to feeding environments outside the home (child care
among families with mother who work outside the home).
Problems
Mild and transient feeding problems occur in 25% to 35% of young children while severe and chronic feeding
1
problems occur in 1% to 2%. Common conditions include overeating, poor eating, feeding behaviour problems
and unusual or unhealthy food choices. Although medical disorders and inappropriate food selection can result
in feeding problems, these conditions are often associated with early problems in parent-child feeding
experiences. Problems with self-regulation, attachment, temperament and the development of autonomy can
contribute. A poor attachment may result from substance abuse or mental illness in the caregiver,
developmental delay or a medical condition in the child, and parent-child personality/temperament conflict.
While most feeding problems in infants and young child are temporary, emotional and social development may
be impacted during late childhood, adolescence and adulthood. Obesity, cardiovascular disease, diabetes
mellitus and behavioural problems are more frequent in those with early childhood feeding problems.
1. Overeating. The prevalence of overweight and obesity in the United States has increased to 10.4% in
two- to five-year olds, 15.3% in six- to 11-year olds, and 15.5% in 12- to 19-year olds.2 These children are
not only at risk for medical problems (e.g. diabetes mellitus, hypertension, orthopedic problems,
obstructive sleep apnea), but also poor self-esteem, disturbed body image, social isolation,
maladjustment, depression and eating disorders. Social stigmatization begins as early as preschool and
continues into school-age as their peers may reject overweight children. Parental concerns about
overeating and obesity may result in inappropriate restriction of their young child’s diet.
2. Poor eating or not gaining sufficient weight. A parent may misperceive her child as having insufficient
nutritional intake when the child is active and more interested in play and the environment than in meals.
Some parents have inappropriate expectations about sufficient food portions and weight gain. Failure to
thrive (FTT) occurs when a child’s rate of weight gain has decreased to below the third to fifth percentile
for gestation-corrected age and sex, or the child’s weight has fallen and crossed two major percentiles in
a standardized growth chart. Children with FTT may have impaired growth (e.g. height, head
circumference) and developmental skills and are at risk for long-term developmental and behavioural
problems.
3. Feeding behaviour problems. Parents may have difficulty making the transition from an infant who is
cooperative during feeding to a toddler who seeks independence at mealtime. Limited food preferences
may be normal and temporary during this period or may develop into a behavioural disorder. Food
phobias or a post-traumatic feeding disorder may result from a painful episode (e.g. choking with a
particular food) or a difficult experience associated with a food-induced allergic reaction.
4. Unusual choices. Pica, or the ingestion of non-food substances, is normal in children under two years of

age who explore their environment through hand-to-mouth experiences. After two years of age, pica is a
behavioural condition more frequent in children with insufficient stimulation, psychological disorders and
mental retardation.
5. Unhealthy food choices. Food preferences are established through exposure and accessibility to foods,
modelling and advertisements. Most “alternative” diets are not harmful, although specific nutrient
deficiencies should be addressed with some (for example, iron and vitamin B12 in vegan diets).
Research Context
Early childhood feeding experiences affect both health and psychological well-being. Because many feeding
problems have their roots in infancy and childhood, current research focuses on determining the antecedents to
these problems and the effectiveness of modifying various factors.
What are the most significant behavioural antecedents to childhood obesity that affect feeding? How can they
be modified? How can behavioural changes be sustained? What are the most effective community-based
interventions that have an impact on optimal nutritional choices and early feeding behaviours? What cultural
determinants influence optimal feeding behaviours in early childhood? How can a better understanding of
unique cultural values and habits influence medical and public-health programs to improve childhood nutrition?
Behavioural research in childhood feeding has focused on breastfeeding (choice, initiation and sustainability),
teaching parents developmentally-appropriate feeding methods, and behavioural programs directed to specific
feeding disorders, including obesity, failure to thrive and anorexia nervosa. In each case, principles of behaviour
modification, health promotion and education have been applied effectively.
Many studies have examined the proposal that breastfeeding protects against the development of obesity later
3,4,5,6,7 8
in life. While some have found an insignificant effect, others have found a significant and even a dose-
9,10,11
response relationship between breastfeeding duration and lower risk of child obesity. Without a consensus,
the benefits of breastfeeding (e.g. establishment of attachment, optimal nutrition and protection against certain
infectious diseases), still support encouraging breastfeeding whenever possible. With breastfeeding, lower
maternal control of food intake and greater maternal responsiveness to infant cues has a beneficial effect on
infant-feeding style and food intake, acknowledges the infant’s ability to self-regulate appropriate food intake,
12
and may contribute to healthier eating patterns.
Child-feeding practices and behavioural interventions may modify patterns of intake. An overview of pediatric
obesity treatment concluded that dietary changes accompanied by behaviour change methods, exercise and
13
parental involvement are important in long-term success. Parental participation and modelling is instrumental
in establishing and changing eating patterns in children. Modelling consumption of healthy foods, such as fruit
14
and vegetables, has a positive effect on the consumption of those foods by children whereas modelling dieting
15
behaviours results in problems in regulating a child’s intake. Television has a powerful influence on the foods
16
children request; limiting television viewing can lessen obesity. Birch and Fisher have written an excellent

17
review detailing the determinants of children’s dietary intake and responses to their modification.
Conclusions
Feeding infants and young children is a behavioural event influencing their growth and development. Early
experiences with feeding set the stage for healthy feeding-associated behaviours in later childhood and
adulthood. Understanding the development of normal feeding behaviour in infants and young children makes it
easier to distinguish between self-limited concerns and those requiring further intervention. Parents and other
caregivers need knowledge about both nutritional content and developmentally appropriate feeding behaviours.
Since earlier onset of problems results in more significant consequences, prevention of feeding disorders and
related behaviour problems should be targeted towards guiding the feeding behaviours of infants and young
children and their feeding relationships with parents and caregivers. Obesity (especially in developed countries)
and undernutrition (especially in developing countries) can be addressed only through a combination of making
healthy food available, ensuring an understanding of age-appropriate feeding practices, and supporting the
emotional health of families. Cultural differences and temperament variations should be incorporated into any
recommendations.
Implications for Policy and Service
1. Establish national dietary guidelines that are specific for children and easily understood and applied by
parents.
2. Promote and support breastfeeding. The goals of Healthy People 2010 are to increase the proportion of
mothers who breastfeed to 75% in the early postpartum period, 50% at six months and 25% at one year.18
Educate pregnant and new mothers on the advantages and maintenance of breastfeeding.
3. Advocate for nutrition in schools. Endorse and fund healthy school lunches and free school breakfasts
(e.g. the United States federal government’s School Breakfast Program19). Remove soda, sweetened
beverages and unhealthy snacks from school campuses.20 Support nutrition education in classrooms.
4. Require regular physical education in schools to promote a healthy lifestyle and to help decrease obesity.
21
5. Restrict television advertisements endorsing unhealthy food choices. Use media to promote healthy
eating and regular physical activity.
6. Increase the availability of affordable fresh foods, especially fruit and vegetables, in low socioeconomic
communities.
7. Promote education about healthy eating habits through public-health messages and increase funding for
public-health campaigns promoting breastfeeding, healthy foods and obesity prevention.
8. Fund research investigating the etiology, prevention and treatment of obesity; factors influencing choice
of breastfeeding, food intake and physical activity; and child-feeding practices in differing socioeconomic
and ethnic groups.
9. Form public and private partnerships to promote healthy eating. Coordinate efforts of policy-makers,
health professionals, community leaders and parents.

References
1. Satter E. The feeding relationship: problems and interventions. Journal of Pediatrics 1990;117(2 Pt 2):S181-S189.
2. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents, 1999-2000.
JAMA - Journal of the American Medical Association 2002;288(14):1728-1732.
3. Baranowski T, Bryan GT, Rassin DK, Harrison JA, Henske JC. Ethnicity, infant-feeding practices, and childhood adiposity. Journal of
Developmental and Behavioral Pediatrics 1990;11(5):234-239.
4. Elliott KG, Kjolhede CL, Gournis E, Rasmussen KM. Duration of breastfeeding associated with obesity during adolescence. Obesity
Research 1997;5(6):538-541.
5. Hediger ML, Overpeck MD, Kuczmarski RJ, Ruan WJ. Association between infant breastfeeding and overweight in young children.
JAMA - Journal of the American Medical Association 2001;285(19):2453-2460.
6. Wolman PG. Feeding practices in infancy and the prevalence of obesity in preschool children. Journal of the American Dietetic Association
1984;84(4):436-438.
7. Zive MM, McKay H, Frank-Spohrer GC, Broyles SL, Nelson JA, Nader PR. Infant-feeding practices and adiposity in 4-y-old Anglo- and
Mexican-Americans. American Journal of Clinical Nutrition 1992;55(6):1104-1108.
8. Kramer MS. Do breast-feeding and delayed introduction of solid foods protect against subsequent obesity? Journal of Pediatrics
1981;98(6):883-887.
9. Gillman MW, Rifas-Shiman SL, Camargo CA Jr., Berkey CS, Frazier AL, Rockett HR, Field AE, Colditz GA. Risk of overweight among
adolescents who were breastfed as infants. JAMA- Journal of the American Medical Association 2001;285(19):2461-2467.
10. Liese AD, Hirsch T, von Mutius E, Keil U, Leupold W, Weiland SK. Inverse association of overweight and breast feeding in 9 to 10-y-old
children in Germany. International Journal of Obesity and Related Metabolic Disorders 2001;25(11):1644-1650.
11. von Kries R, Koletzko B, Sauerwald T, von Mutius E, Barnert D, Grunert V, von Voss H. Breast feeding and obesity: cross sectional study.
BMJ - British Medical Journal 1999;319(7203):147-150.
12. Fisher JO, Birch LL, Smiciklas-Wright H, Picciano MF. Breast-feeding through the first year predicts maternal control in feeding and
subsequent toddler energy intakes. Journal of the American Dietetic Association 2000;100(6):641-646.
13. Epstein LH, Myers MD, Raynor HA, Saelens BE. Treatment of pediatric obesity. Pediatrics 1998;101(3 Pt 2):554-570.
14. 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.
15. Johnson SL. Improving preschoolers' self-regulation of energy intake. Pediatrics 2000;106(6):1429-1435.
16. Robinson TN. Reducing children's television viewing to prevent obesity: a randomized controlled trial. JAMA- Journal of the American
Medical Association 1999;282(16):1561-1567.
17. Birch LL, Fisher JO. Development of eating behaviors among children and adolescents. Pediatrics 1998;101(3 Pt 2):539-549.
18. US Department of Health and Human Services. Maternal, infant and child health. In: Healthy people 2010: Conference edition. Vol 2.
Washington, DC: US Government Printing Office; 2000:47-48. Available at:
http://www.healthypeople.gov/Document/HTML/Volume2/16MICH.htm. Accessed September 20, 2005.
19. McBean LD, Miller GD. Enhancing the nutrition of America's youth. Journal of the American College of Nutrition 1999;18(6):563-571.
20. American Academy of Pediatrics, Committee on School Health. Soft drinks in schools. Pediatrics 2004;113(1 Pt 1):152-154.
21. American Academy of Pediatrics. Physical fitness and activity in schools. Pediatrics 2000;105(5):1156-1157.

Helping Children Develop Healthy Eating
Habits
Maureen M. Black, PhD, Kristen M. Hurley, PhD
University of Maryland School of Medicine, USA
September 2013, 2nd rev. ed.
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
1,2
a chew-swallow mechanism with semi-solids, progressing to complex textures. 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
3
between dietary variety and nutritional status. Exposure to fruits and vegetables in infancy and toddlerhood
4-6
have been associated with acceptance of these foods at later ages.
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
7
new skills and are challenged with new foods or mealtime expectations. 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)
8
and insist on a limited repertoire of foods, 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

9
long-term health and developmental problems. 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
10
behaviours and food preferences that include excess amounts of fat and sugar. At the environmental level,
children’s frequent exposure to fast-food and other restaurants has led to increased consumption of high-fat
11
foods, such as french fries, rather than more nutritious options, such as fruit and vegetables. In addition,
caregivers may not realize that many commercial products marketed for children, such as sweetened drinks,
12
may satisfy hunger or thirst, but provide minimal nutritional benefits.
13,14
National surveys have reported excessive caloric intakes during toddlerhood, and many children continue to
15
consume alarmingly low quantities of fruit and vegetables and essential micronutrients. By elementary school,
16
many children receive over half their beverage intake from sweetened drinks, 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
17
deficiencies (e.g., Iron Deficiency Anemia) and excess weight gain in young children.
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 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.
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
18
to healthy social functioning. 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
9
include eating. Infants who are premature or ill may be less 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

19
Variability in the caregiver-child feeding context is related to children’s eating behaviour and growth. The
dimensions of parental structure and nurturance, which incorporate parents’ perceptions of their child’s
20,21,22
behaviour, have been applied to the feeding context (Figure 1). 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
23,24
routines (uninvolved feeding).
Figure 1. The Caregiver-Child Feeding Context: Patterns of Parenting and Feeding
NURTURANCE
HIGH LOW
AUTHORITATIVE AUTHORITARIAN
Involved Forceful
Nurturing Restrictive
HIGH
Structured Structured
Responsive Controlling
INDULGENT UNINVOLVED
Involved Unengaged
Nurturing Insensitive
LOW
Unstructured Unstructured
Indulgent Uninvolved
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,
22,25,26
contingent on the child’s behaviour and developmentally appropriate with an easy give-and-take.
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
27
overpowering the child. Controlling caregivers may override their child’s internal regulatory cues for hunger
28
and satiety. The innate capacity that infants have to self-regulate their energy intake declines during early
29
childhood in response to family and cultural patterns.
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
23
they will eat. Without parental guidelines, children are likely to be attracted to high salt/high sugar foods, rather
23
than to a more balanced variety including vegetables. Thus, an indulgent feeding style may be problematic,
30
given infants’ genetic predispositions to prefer sweet and salty tastes. Children of caregivers who display an
24
indulgent feeding style are often heavier than children of caregivers who use non-indulgent feeding styles.
An uninvolved feeding style, low in both nurturance and structure, often represents caregivers who have limited
23
knowledge and involvement in their child’s mealtime behaviour. 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
31
may be unaware of what or when their toddler is eating. Egeland and Sroufe 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
23
parenting.
Several recent systematic reviews report associations between parental feeding control and infant and early
24,32,33
child weight gain and/or weight status. Controlling feeding has been associated with increased weight gain
34
(e.g., children of caregivers who use restrictive feeding practices tend to overeat) and to decreased weight
35
gain (e.g., children who are pressured to eat more, do not). 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
36
behaviour. 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
4
vegetables, establish food preferences that include fruit and vegetables.
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.
37,38
Increasing familiarity with the taste of a food increases the likelihood of acceptance. 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 between responsive/unresponsive feeding and children’s eating behaviour
24
and weight gain and population-specific validated tools to measure responsive/unresponsive feeding.
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
39
communicate hunger and satiety, as well as enjoyment of specific foods.
Caregivers control both the food that is offered and the mealtime atmosphere. Their “job” is to ensure that
39
children are offered healthy food on a predictable schedule in a pleasant setting. 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
39
the day, so they develop an expectation and an appetite around mealtime.
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 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
40
problems.
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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.
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.

Assessment and Treatment of Pediatric
Feeding Disorders
1 1 2
Suzanne M. Milnes, PhD, Cathleen C. Piazza, PhD, Tammy Carroll, PhD
1
Munroe-Meyer Institute, University of Nebraska Medical Center, USA,
2
University of Alabama, USA
September 2013, Rev. ed.
Introduction
A feeding disorder is identified when a child is unable or refuses to consume a sufficient quantity or variety of
1
solids and liquids to maintain proper nutrition. The complications from feeding problems range from mild (e.g.,
2
missed meals) to severe (e.g., severe malnourishment). Mealtime difficulties occur in approximately 25% to
3-6
35% of typically developing children and up to 80% of individuals with developmental disabilities. Feeding
disorders may be manifested by total refusal to eat, dependence on supplemental feedings (e.g., gastrostomy
tube), inappropriate mealtime behaviour, and selectivity by type and texture.
Subject
The causes of feeding disorders are equally varied. Feeding problems are often caused by a number of
7,8
biological and environmental factors, which interact. For example, Rommel et al. evaluated 700 children
referred to an interdisciplinary feeding team and found combined causes (e.g., medical, behavioural, oral-
8
motor) of the feeding problem occurred in over 60% of patients.
Biological factors may include early experiences with medical procedures, chronic hospitalization, or medical
problems, which cause eating to be painful. Even after the painful medical condition is treated, the child may
continue to refuse food because if the child never or rarely eats, he or she never learns that eating is no longer
painful. If the child refuses to eat, he or she does not have the opportunity to practice eating and does not
develop the skills to become a capable eater. Refusal to eat may lead to growth failure, which contributes to
9
poor feeding skills as undernourished children lack the energy to become capable eaters. Thus, a cycle
develops in which the child refuses food, fails to learn that eating is no longer painful, misses opportunities to
develop oral motor skills, and fails to gain weight.
Problems
Even when the cause of food refusal is a painful medical condition, caregiver responses to the child during
meals may worsen the problem. Piazza and colleagues observed caregivers and children with feeding
problems during meals, which showed that caregivers used a variety of strategies to encourage eating such as
distracting, coaxing, and reprimanding; allowing the child to periodically take a break from or avoid eating; and
10
providing preferred food or toys. All children displayed refusal behaviour and infrequently ate bites of food.

When Piazza et al. analyzed the effects of caregiver behaviour during meals on child feeding behaviours,
results indicated that the above listed strategies used by the caregivers to encourage eating actually worsened
10
behaviour for 67% of the children.
These results are not surprising given the relation between the causes of feeding problems and caregiver
behaviour. Parental strategies such as stopping the meal or coaxing may produce the immediate effect of
temporarily stopping undesirable child behaviour. From the child’s perspective, the study by Piazza et al.
suggested that if refusal behaviour produces a “good outcome” for the child (e.g., the meal ends), refusal will
10
continue.
Research Context
11-16
The treatment strategies with the most scientific support are based on behaviour analysis. Kerwin and
Volkert and Piazza examined the research literature on treatment of pediatric feeding disorders to identify which
treatments had enough scientific support to be labeled “effective.” Kerwin and Volkert and Piazza found that
behavioural interventions were the only treatments with enough scientific evidence to be labeled “effective.”
Similar analyses by Sharp and colleagues, Ledford and Gast, and Williams and colleagues supported those of
11,13-16
Kerwin and Volkert and Piazza.
Research Results and Conclusions
Because children have feeding problems for a variety of reasons, treatment should focus on all of the
components (i.e., biological, oral motor and psychological) that contribute to feeding problems and should be
17,18
interdisciplinary. One preliminary analysis of the outcomes for 50 children admitted to an interdisciplinary
day-treatment feeding program indicated that over 87% of the goals for treatment were met by discharge from
the program. When increases in calories consumed by mouth were the goal of treatment, 70% of patients
reached their goal. Even when children did not reach 100% of their oral intake goal, their levels of oral intake
were increased substantially and within 20% of the goal One hundred percent of patients met their goals for
increasing texture, decreasing bottle dependence, increasing self-feeding skills, and increasing variety of foods
consumed.
All patients receiving their nutrition via tube experienced decreases in tube feedings and 70% of patients met
their goals for decreases in tube feedings. Patients who entered the program with a nasogastric tube either left
the program without the tube (75%), or the tube was removed shortly after discharge (100%). Ninety-seven
percent of patients met their goals for decreasing inappropriate mealtime behaviour. Eighty-eight percent of
caregivers were trained to implement the treatments with greater than 90% accuracy, and the treatment was
transferred successfully to the home and community in 100% of cases.
Follow-up data indicated that the majority of patients continued to make progress toward age-typical feeding
17
(e.g., volume increases gastrostomy-tube feeding decreases and initiation of self-feeding). Williams and
colleagues, Greer and colleagues, and Laud and colleagues provided similar data in that interdisciplinary
treatment with a behaviour analysis focus produces positive outcomes for children with severe feeding
19-21
problems.

Implications
Interdisciplinary, intensive treatment of pediatric feeding disorders is successful in improving a wide variety of
feeding problems, including dependence on supplemental feedings, selectivity by type and texture of food,
inappropriate mealtime behaviour, failure to transition to age appropriate textures of food, and failure to self-
feed to name a few. Successful treatment of these feeding problems has a number of important implications for
children with feeding problems, their families, and society. Long-term, chronic feeding problems are associated
22 23
with (a) health risks for the child, (b) increased perceived stress for the child and family, (c) mental health
24 25
problems in families, (d) increased risk of eating disorders such as anorexia, and (e) increased health care
19
costs for the child and family. Therefore, treatment of pediatric feeding problems can result in (a) improved
health of the child, (b) improved quality of life for the child and family, (c) decreased mental health problems in
families, (d) reduced risk of long-term eating problems, and (e) reduced health care costs. Obviously, children
who are dependent on technology such as gastrostomy-tubes (G-tube) for their nutritional needs have high
health care costs. For example, the health care cost for a child with a G-tube is approximately $41,811 for the
first year. Over two years, the health care cost for that child is estimated to be $78,811 and after five years, the
cost is $189,811. These estimates are for uncomplicated care (e.g., no other significant medical problems
related to the gastrostomy-tube) and do not include costs associated with family or individual therapy that may
be necessary as a result of increased stress or psychopathology that has been documented in families of
children with feeding problems. Moreover, the health care costs for these children may extend over many years
if the child continues to need the gastrostomy-tube for nutrition or if the child develops eating problems such as
anorexia later on. Williams and colleagues found that intensive, behavioural treatment was a cost-effective
19
alternative to long-term supplemental feedings. Intensive, interdisciplinary treatment for feeding problems can
eliminate the need for a gastrostomy-tube and result in age typical feeding, which can end the need for ongoing
medical treatment in about 2 years. The estimated cost of intensive treatment for the feeding problem is
approximately $55,620 over 2 years. Thus, treatment of the feeding problems results in a savings of $23,191
over a 2-year period and a cost savings of a minimum of $134,191 over 5 years when compared to using a
gastrostomy-tube for the problem.
Thus, not only are there obvious quality of life improvements for children with feeding problems and their
families, but also there are significant cost savings when feeding problems are treated using interdisciplinary
approaches with a behaviour-analytic focus.
References
1. Babbitt RL, Hoch TA, Coe DA, Cataldo MF, Kelly KJ, Stackhouse C, Perman JA. Behavioral assessment and treatment of pediatric feeding
disorders. Developmental and Behavioral Pediatrics 1994;15(4):278-291.
2. Polan HJ, Kaplan MD, Kessler DB, Shindledecker R, Newmark M, Stern DN, Ward MJ. Psychopathology in mothers of children with failure
to thrive. Infant Mental Health Journal 1991;12(1):55-64.
3. Field D, Garland M, Williams K. Correlates of specific childhood feeding problems. Journal of Pediatric Child Health 2003; 39: 299-304.
4. Gouge AL, Ekvall SW. Diets of handicapped children: Physical, psychological and socioeconomic correlations. American Journal of Mental
Deficiency 1975;80(2):149-157.
5. Palmer S, Horn S. Feeding problems in children. In: Palmer S, Ekvall S, eds. Pediatric nutrition in developmental disorders. Springfield, Ill:
Charles C. Thomas; 1978:107-129.
6. Perske R, Clifton A, McClean BM, Stein JI. Mealtimes for severely and profoundly handicapped persons: New concepts and attitudes.
Baltimore, MD: University Park Press. 1977.

7. Burklow KA, Phelps AN, Schultz JR, McConnell K, Rudolph C. Classifying complex pediatric feeding disorders. Journal of Pediatric
Gastroenterology & Nutrition 1998;27(2):143-147.
8. Rommel N, DeMeyer AM, Feenstra L, Veereman-Wauters G. The complexity of feeding problems in 700 infants and young children
presenting to a tertiary care institution. Journal of Pediatric Gastroenterology and Nutrition 2003;37(1):75-84.
9. Troughton KE, Hill AE. Relation between objectively measured feeding competence and nutrition in children with cerebral palsy.
Developmental Medicine and Child Neurology 2001;43(3):187-190.
10. Piazza CC, Fisher WW, Brown KA, Shore BA, Patel MR, Katz RM, Sevin BM, Gulotta CS, Blakely-Smith A. Functional analysis of
inappropriate mealtime behaviors. Journal of Applied Behavior Analysis 2003;36(2):187-204.
11. Kerwin ME. Empirically supported treatments in pediatric psychology: severe feeding problems. Journal of Pediatric Psychology
1999;24(3):193-214.
12. Laud RB, Girolami PA, Boscoe J H, Gulotta C S. Treatment outcomes for severe feeding problems in children with autism spectrum
disorders. Behavior Modification 2009; 33(5): 520-536.
13. Ledford JR, Gast DL. Feeding problems in children with autism spectrum disorders: A review. Focus on Autism and Other Developmental
Disabilities 2006; 21: 153-166.
14. Sharp W G, Jaquess D L, Morton J F, Herzinger C V. Pediatric feeding disorders: A quantitative synthesis of treatment outcomes.
Clinical Child and Family Psychology Review 2010.
15. Volkert VM, Piazza CC. Empirically supported treatments for pediatric feeding disorders. in: Sturmey P, Herson M, eds. Handbook of
Evidence Based Practice in Clinical Psychology. Hoboken, NJ: Wiley, USA. in press
16. Williams KE, Field DG, Sieverling L. Food refusal in children: A review of the literature. Research in Developmental Disabilities 2010; 31:
625-633.
17. Cohen SA, Piazza CC, Navanthe A. Feeding and nutrition. In: Rubin IL, Crocker AC, eds. Medical care for children and adults with
developmental disabilities. Baltimore, MD: Paul Brooks Publishing. 2006; 295-307.
18. Piazza CC. Feeding Disorders and behavior: What have we learned? Developmental Disabilities Research Reviews 2008; 14: 174-181.
19. Williams KE, Riegel K., Gibbons B, Field DG. Intensive behavioral treatment for severe feeding problems: A cost-effective alternative to tube
feeding. Journal of Developmental and Physical Disabilities 2007; 19: 227-235.
20. Greer AJ, Gulotta CS, Masler EA, Laud RB. Caregiver stress and outcomes of children with pediatric feeding disorders treated in an
intensive interdisciplinary program. Journal of Pediatric Psychology 2008; 33(6): 612-620.
21. Laud RB, Girolami PA, Boscoe JH, Gulotta CS. Treatment outcomes for severe feeding problems in children with autism spectrum disorder.
Behavior Modification 2009; 33(5): 520-536.
22. Berezin S, Schwarz SM, Halata MS, Newman LJ. Gastroesophageal reflux secondary to gastrostomy tube placement. American Journal of
Diseases in Childhood 1986;140(7):699-701.
23. Singer LT, Song L-Y, Hill BP, Jaffe AC. Stress and depression in mothers of failure-to-thrive children. Journal of Pediatric Psychology
1990;15(6):711-720.
24. Duniz M, Scheer PJ, Trojovsky A, Kaschnitz W, Kvas E, Macari S. Changes in psychopathology of parents of NOFT (non-organic failure to
thrive) infants during treatment. European Child and Adolescent Psychiatry 1996;5(2):93-100.
25. Kotler LA, Cohen P, Davies M, Pine DS, Walsh TB. Longitudinal relationships between childhood, adolescent, and adult eating disorders.
Journal of the American Academy of Child & Adolescent Psychiatry 2001;40(12):1434-1440.

Genetic Influences on Child Eating
Behaviour
Clare Llewellyn, PhD, Jane Wardle, PhD
Health Behaviour Research Centre, University College London, United Kingdom
September 2013
Introduction
1 2
Obesity is a global epidemic; its prevalence is increasing and it is developing earlier in childhood. It is
therefore crucial to identify causal factors underlying early weight gain. Recent changes to the environment –
such as increased opportunity to eat high calorie food and decreased opportunity to be physically active – have
3,4
undoubtedly played a role. Nonetheless, not everyone is overweight. Body weight has a strong genetic basis,
leading to the hypothesis that genes may influence how vulnerable an individual is to gaining weight in the
5
modern environment. Genetically-determined susceptibility to the environment would help to explain how
obesity can be both genetic and environmental.
Subject
Eating behaviour, or appetite, has been proposed as one mechanism through which genes influence obesity
5,6
susceptibility. In particular, individuals who inherit a more avid appetite – high responsiveness to external food
cues and low sensitivity to internal satiety (fullness) processes – may be more likely to take advantage of the
multiple eating opportunities presented by the modern environment, and consequently gain more weight. That
is, genes may influence how big or small an individual’s appetite is, and ultimately these genes therefore impact
on their weight, so-called “inherited behavioural susceptibility to obesity.”
Problems and Research Context

7-11
Eating behaviours of interest are those with evidence for a causal role in early life weight gain. Broadly these
can be thought of as “food approach” behaviours which indicate a bigger appetite and a greater interest in food
11 8,11
(e.g., enjoyment of food and responsiveness to external food cues ) and predispose to weight gain, and
‘food avoidance’ behaviours which suggest better appetite regulation and a lower interest in food (e.g.,
9,11 7,10,11
sensitivity to satiety and slower eating speed ) and protect against weight gain. Observational
measurement of eating behaviour provides detailed information, but is time-consuming and expensive so the
number of observations is limited, which is problematic for genetic research which requires large samples (see
below). It is also possible that participants alter their eating behaviour in response to being observed, especially
self-conscious overweight adults. Using children instead of adults helps get around this issue, and the
development of a parent-report measure of child eating behaviour (the Child Eating Behavior Questionnaire
12,13 14
[CEBQ] or the Baby Eating Behavior Questionnaire [BEBQ] ) has enabled information to be collected
reliably on very large samples, for a range of eating behaviours.
Two different approaches allow researchers to explore genetic influences on eating behaviour. So-called
“quantitative genetic” studies estimate broadly the extent to which behaviour is influenced by genes or
15
environment. Studies compare family members who differ in their genetic relatedness – if relatives who are
more genetically similar are also more similar for eating behaviour, genetic influence is inferred. Twins are
commonly used because identical twins (monozygotic pairs, MZs) are 100% genetically identical, while non-
identical or “fraternal” twins (dizygotic pairs, DZs) share on average only about 50% of their genes, like regular
siblings. At the same time, MZs and DZs can be assumed to share environmental factors to a very similar
extent (e.g., they are born at the same time into the same family), so they can be compared. Greater similarity
15
between MZs compared to DZs suggests that genes influence eating behaviour. Heritability is the statistic
that is derived from twin studies, and it indicates the extent to which individual differences in the sample are
explained by genetic variation. The statistic ranges from 0% (genetic variation does not contribute to individual
differences) to 100% (individual differences can be explained entirely by genetic variation).[1] Twin studies are
limited in that they cannot tell us anything about the actual genes involved, they simply indicate the relative
importance of genes versus environment.
Molecular genetic studies try to identify the specific genes. Early research studied individuals and families with
16
extreme manifestations of the trait – e.g., severe early onset obesity – to find genes. These studies identified
genes responsible for rare and serious genetic disorders, but not common genes influencing variation across
the general population (e.g., body weight). Recent technological advances combined with the completion of the
Human Genome Project in 2000 have made it possible to explore the impact of millions of genetic variants on
17
traits across the wider population, using a method called genome-wide association (GWAS). Large samples
15
are needed for quantitative genetic studies and even larger samples for molecular genetic studies.
1. Is eating behaviour heritable?
2. Which genes influence eating behaviour?
3. Do weight-related genes influence weight via eating behaviour?

The high heritability of body weight in children and adults (~70%) is a long-standing finding established from a
3,4
wealth of twin and family studies. Similar heritability estimates have been found for infant and child eating
behaviour. The CEBQ was used in 5,435 pairs of 10 year old British twins to demonstrate that the majority of
individual differences in responsiveness to food cues and satiety responsiveness are determined by genes
5
(75% and 63% respectively). A similar estimate was obtained for an observational measure of eating speed
18 19
(63%) in a subsample of 254 of these twins at age 11. An infant-version of the CEBQ (the BEBQ ) showed
comparably high heritability estimates for enjoyment of food (53%), food responsiveness (59%), satiety
20
responsiveness (72%) and slowness in eating (84%), in 2,402 infant twin pairs. The same sample of infant
twins was also used to show that about a third of the genes that influence eating behaviours influence weight as
21
well, supporting the idea that genes influence weight via their effects on eating behaviour.
Early studies of obese individuals and families identified major mutations in one of a few genes resulting in
22
severe early-onset obesity, as well as extreme appetite voraciousness and no apparent satiety. These genes
are fundamental regulators of the leptin-melanocortin pathway that controls hunger and satiety centrally, and is
located in an ancient part of the brain called the hypothalamus. While the discovery of these genetic mutations
provided important insights into the biology of body weight and eating behaviour, they are extremely rare and
therefore do not explain weight variation at the population level.
Genome-wide association studies (GWAS) have identified more than 30 common genetic variants associated
23
with body weight in adults and children. The first to be discovered was the “fat mass and obesity-associated
24
gene,” FTO. Nearly half of us carry at least one of the weight-related FTO variants; and those of us carrying
two are on average 3 kilograms heavier than those carrying none. Not only is FTO expressed primarily in the
hypothalamus, but it is associated with observational measures of food responsiveness measured at test meals,
25 26
and with satiety responsiveness as measured by the CEBQ. Many of the other variants discovered through
GWAS are also expressed in the hypothalamus, suggesting that common genetic variants, like the rare
mutations, influence body weight through eating behaviour. However, as yet relationships between these other
common variants with eating behaviour have not been explored.
Research Gaps
Although research has made headway in establishing that eating behaviour, like weight, has a strong genetic
basis, we still know very little about the specific genes involved. A good starting point would be to explore
whether the weight-related common genes identified so far are also associated with eating behaviour. The
biology linking genes to behaviour also needs to be characterized. In addition, it is crucial to test the feasibility
of modifying eating behaviour in individuals who are genetically susceptible to obesity. There has been little
research into modifying eating behaviour so far, but some studies are promising. Epstein and colleagues
succeeded in slowing the eating speed of 7 year old children over a 6-month period by encouraging them to put
27
their knife and fork down after each bite. Another study demonstrated that it is possible to train 4-5 year old
28
children to become better at recognizing and attending to their internal satiety sensations.
Conclusions

Twins studies have established that differences between individuals in eating behaviour is explained partly by
genetic variation, in typical western societies at this time; although the actual genes involved remain to be
identified. Twin studies have also shown that the same genes which influence eating behaviour also influence
weight, suggesting that the size of an individual’s appetite ultimately influences their vulnerability to obesity in
the modern permissive environment. In support of this, the most important common weight-related gene (FTO)
appears to influence body weight through its effects on satiety sensitivity in children. This so-called inherited
behavioural susceptibility to obesity helps to overcome the seeming paradox of both genetic and environmental
determination of weight.
Genetic influences on child eating behaviour
Image not readable or empty

/sites/default/files/images/contenu/figure-1-genetic-influences-on-child-eating-behaviour-llewellyn-wardle.jpg
Figure 1 is a hypothetical demonstration of the percentage of children who are obese under three different environmental conditions, according to
whether they have a low, average or high genetic susceptibility to obesity.29-30 Under conditions of famine there would be no obese children,
regardless of genetic susceptibility to obesity; when the food supply is limited slightly more of the children at high genetic susceptibility would be
obese than those at average susceptibility, but none of the children at low genetic susceptibility would be obese; under conditions of abundance (like
the modern food environment in the U.S.) the majority of children at high genetic susceptibility would be obese, a considerable number at average
genetic susceptibility, but very few children at low genetic susceptibility would be obese.
Implications for Parents, Services and Policy
This research suggests that some individuals are more vulnerable to overeating in response to the multiple
opportunities presented by the modern food environment, by virtue of their genes, and more likely to gain
weight. This calls into question the notion of personal responsibility for obesity. It is a commonly held belief that

a child’s weight reflects the rearing strategies of the parent. However, this research suggests that some children
31
(more often those who have overweight parents and are therefore likely to have inherited higher risk genes.
may find it harder than others to regulate their food intake appropriately because they have a more avid
appetite, which is partly due to genes inherited from their parents. This can make it more difficult to resist over-
consuming in response to the many eating opportunities presented by the modern environment.
[An effective strategy might be tighter state regulation of the wider food environment to reduce opportunities
and incentives for overconsumption, such as removal of vending machines from schools, tighter control of food
32
marketing to children, limitation of the number of fast food venues, and regulation of supermarket layouts.
Parents can also modify the home environment – e.g., by cooking smaller amounts of dinner to remove the
temptation for “seconds,” keeping problem foods out of sight (or better, out of the home), and teaching their
children how to recognize feelings of fullness.
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31. Whitaker KL, Jarvis MJ, Beeken RJ, Boniface D, Wardle J. Comparing maternal and paternal intergenerational transmission of obesity risk in
a large population-based sample. Am J Clin Nutr 2010;91(6):1560-1567.
32. Gostin LO. Law as a tool to facilitate healthier lifestyles and prevent obesity. JAMA 2007;297(1):87-90.

Television (TV) and TV Advertisement
Influences on Children’s Eating Behaviour
Chrisa Arcan, PhD, Meg Bruening, MPh, RD, Mary Story, PhD
University of Minnesota, USA
September 2013
Introduction
While multiple factors influence eating behaviours and food choices of youth, two potent forces are television
(TV) viewing and exposure to TV food advertising. In the United States, children and adolescents watch TV for
1
almost four and a half hours each day. During this time, children between the ages of 2 to 12 are exposed to
up to a total of 38 minutes of advertising each day. Food advertising accounts for half of all advertising time in
children’s TV programs. Children between 2 to 7 years see 12 food ads and those between 8 to 12 years see
2
21 food ads each day, or 7,609 ads each year. While some data indicate that food advertising to young
3
children has decreased since a peak in 2004, the number of food advertisements and the types of foods
advertised remains disturbing.
A major determinant of food preferences is taste. Eating habits and taste preference develop early in life and
4,5
remain relatively stable through young adulthood. As taste preferences are acquired through learning
6
processes including repeated exposure and positive messaging about various foods, exposure to TV viewing
early in life can have a marking lifelong influence in eating practices.
Subject
Food and beverage marketing and children’s eating behaviours
Food and beverage marketing is a major factor that influences children’s food preferences and purchasing
6-8
requests. Marketers use many avenues to reach children with their messages such as using popular cartoon
9-11
characters and toy giveaways to increase the pester-power of youth. Billboards, in-school advertisements,
TV commercials, product placement in television shows/movies/video games and in grocery stores, Internet
6,9
websites and games, and smart phone applications are often used to deliver messages and engage youth.
While technology and advertising techniques are changing, television remains the most prominent method of
3,12
marketing food and beverages to youth, especially for those in early childhood. Annually, the food and
beverage industry spends $1.23 billion on marketing food and beverages to children under the age of 12 years.
13
Exposure to unhealthy TV food marketing
The diets of American children are inadequate in nutrient-dense foods (i.e., fruits, vegetables, low-fat dairy, and
whole grains), and are high in energy-dense foods and beverages (i.e., chips, fast food, soda). More than any

other foods/beverages, children are exposed to marketing messages for unhealthy foods, such as sugary
breakfast cereals, fast food restaurants and snack foods such as chips, desserts, candy, sugar-sweetened
3,14
beverages, and yogurt. Exposure to unhealthy foods through TV marketing has been linked to increased
7,10,15
preferences for marketed foods. Since most of children’s food preferences are formed during early
16
childhood children are at risk for forming life-long preferences for foods laden in calories, fat, and added
6,15,17
sugars and, thus, are also at increased risk for obesity due to TV food marketing practices.
Research Context
Influence of TV viewing and advertising on eating behaviours of children
As one-third of U.S. children and adolescents are overweight or obese, it is critical to examine the extent to
which TV viewing and TV food advertising negatively influence current and future eating behaviours among
children and adolescents. It is also important to discuss potential regulations that can protect children from TV
ads and deceptive marketing. Finally, given the ubiquitous nature of TV advertising, implications for policy,
parents and service providers will be discussed.
Is there an association between TV viewing and advertising and eating behaviours?
Is there a difference in exposure to TV advertising among various racial groups?
Are TV viewing and TV food advertising associated with diet-related health issues such as obesity in
children?
Are policies and recent industry self-regulation of TV advertising effective in influencing eating behaviours
of children?
The association between TV viewing / advertising and children’s eating behaviours
It has been documented that among young children, TV viewing is significantly associated with increased
18
consumption of unhealthy foods, including fast food, increased requests of foods seen on TV, and more
8,19
positive attitudes toward unhealthy foods. The Institute of Medicine (IOM) committee conducted a systematic
review of the scientific evidence and concluded that TV advertising influences the food preferences, purchase
6
requests and diets, at least of children under age 12 years. This evidence is more apparent in younger groups
as more studies have been conducted with younger children than with adolescents.
Recent cross-sectional studies with young children have shown that exposure to food advertising was
20,21
associated with increased consumption of advertised brands, energy-dense foods, soda and fast food, but
overall food consumption was only related to television viewing and not to advertising exposure in some studies.
20
There are few prospective studies supporting the negative impact of TV viewing on dietary behaviours; an
22
increase of 167 kcal/day was found per each hour of increase in TV viewing among 11 year old children. The
only study with older adolescents found that those who were heavy TV viewers during high school had less

23
healthful eating habits during the transition to young adulthood.
Several experimental studies have demonstrated the effect of TV food advertising on increasing food intake.
4,15,24,25
In a recent experiment, elementary school-aged children who saw unhealthy food advertising while
watching a children’s cartoon program consumed 45% more snacks than the group of children who watched the
4
program with non-food advertising. Conversely, children’s attitudes and beliefs toward healthy foods were
positively impacted by advertisements of healthy foods, but these positive effects were reduced when
8
advertisements of unhealthy foods were shown alongside healthy foods.
Ethnic minority exposure to TV viewing and advertising

26
Recent findings indicate that food marketing to ethnic minority groups has increased in the past decade. There
1
are racial disparities in media use and the greatest differences are for TV time. However, research on TV
viewing and food advertising practices targeting ethnic minority populations is still scarce. The few available
studies show that a higher proportion of food advertisements seen by black children are for fast food
14,27-29
restaurants or they are higher in sugar than advertisements seen by white children. Hispanic preschool
30
children see almost 300 advertisements for fast foods each year on Spanish-language channels alone. Given
the high rates of overweight and obesity among minority children and the higher consumption of sugar-
31
sweetened beverages by African American and Hispanic than white children, these findings are especially
concerning.
Television advertising and obesity
Although there is a substantial scientific evidence demonstrating the link between duration of TV viewing and
18,32
children adiposity as well as TV viewing behaviour and future adiposity, fewer studies have shown a direct
association between exposure to TV advertisement and obesity. Studies have also found a link between fast
33
food restaurant advertising and body mass index, indicating that if fast food advertising was banned, it would
33
reduce the number of overweight 3 to 11 year old children by 18%. Given the challenges involved in directly
assessing the effect of advertising on obesity, simulation studies have been conducted. According to these
studies, in the absence of TV advertising for food, the rate of overweight and obesity for 6 to 12 year old
34,35
children would have been reduced by about 25% and 40%, respectively.
The role of family on exposure to TV viewing and advertising
Family communication and media education is an important component in mediating the negative effects of
advertising on children’s dietary behaviours. Although limited research exists in this area, the findings indicate
that parental communication about advertising and setting rules about food consumption was more successful
36
in reducing energy-dense food consumption by their children than open discussion about consumption.
However it was more effective when parents imposed restrictions of advertising exposure to pre-school and
36
early elementary school children than to older children.
Policies to limit television food advertising
The U.S. has a few regulations regarding TV food and beverage advertising to children, including industry self-
regulatory policies. However, federal agencies have limited power to regulate against unfair and deceptive

37
advertising practices to children. In 2006, in partnership with the Council of Better Business Bureau’s
Children’s Food and Beverage Advertising Initiative (CFBAI), a coalition of food companies pledged to improve
38
the nutritional quality of foods advertised to children under the age of 12 years. Also, the IOM committee has
offered 10 recommendations to address activities by the food industry and public sector to support a healthful
6
diet to children and adolescents. A review evaluating the progress made by industry stakeholders in marketing
healthful foods to children revealed that food and beverage companies made some progress in promoting
healthier products, but that limited progress was made by restaurants, industry trade associations and the
38
media. Despite the reported progress, overall TV food advertising to young children has increased by 9%
39
between 2008 and 2010. In addition, more than a quarter of all food/beverage advertising to children is from
38,40
companies that do not participate in the coalition, including the majority of fast food establishments.
Research Gaps
While progress has been made in assessing the degree of exposure and content of TV advertisement to
children and adolescents, more research is needed to elucidate the mechanisms involved in the exposure of TV
advertisement and dietary choices of children. Also, there are research gaps on the effect of healthy
food/beverage advertisement on the consumption of these foods. A benefit to policy initiatives will be to
understand whether increased exposure to healthy food advertisement would cause a shift in children’s
consumption and preference for healthy foods and beverages. Family plays an important role, especially during
the formative years, in modeling behaviour and enforcing rules and restrictions. Therefore, more research is
needed to unveil the effects of parental communication styles relative to consumer-related issues on children’s
food choices. In addition, targeting parents to increase awareness about the food industry’s marketing practices
41
is needed. The effectiveness of the food industry’s self regulation initiative has yet to be established,
therefore, further studies are essential to evaluate the advertising activities of the participating companies.
Conclusions
Children and adolescents spend a considerable amount of time watching television. As a result, youth are
exposed to a large number of food and beverage advertisements each day. Among ethnic minority groups, this
exposure is even higher. Television viewing is associated with unhealthy food consumption among children.
There is sufficient evidence that TV advertising influences the food preferences, purchase requests and diets of
children under the age of 12 years. Experimental studies supported the causal relationship of food advertising
on children’s eating behaviours, demonstrating that immediately following the food commercials young children
were more likely to increase their caloric intake and snack foods. Although research is limited in the area of
parental communication about food advertising, it has been shown that parental communication about food
advertising and setting restrictions on advertising exposure protects against energy-dense food consumption
among young children. From findings to date, causal relationship cannot be drawn between TV advertising
exposure and obesity, however significant associations have been found between fast food advertising and
child body mass index. Limited regulations on marketing to children exist in the U.S. and various European
37
countries have a range of statutory and self-regulatory rules in place. While Canada has a well-established
system of self regulation, Quebec is the only province prohibiting commercial advertising directed at children
42
under the age of 13.

Implications for Parents, Services and Policy
Despite the industry’s positive actions to promote healthy lifestyles to children, companies continue to fail to
protect children and adolescents from advertising unhealthy products as close to 69% of all advertising by
40
companies participating in the coalition was for poor nutritional quality. The food/beverage industry’s self-
regulation addresses the health needs of children ages 12 and younger leaving a large population of youth who
have greater purchasing power and more autonomy to make food choices. Policies for nutrition and marketing
standards should be implemented and enforced by federal, state and local governments in order to achieve
uniform protection of the diets and health of children and youth.
According to American Academy of Pediatrics, children below the age of 2 should not watch TV and anyone
42
older than 2 years should only watch 1 to 2 hours of quality programming per day. Health care providers
should be abreast of the latest research and policies regarding TV viewing and children’s dietary behaviours
and obesity. At well-child visits, health care practitioner should discuss with families their TV habits and inform
them about the negative impact of food advertising on children’s dietary behaviours.
Families play an important role in the lives of young children who depend on them for nourishment, role
modeling, and setting rules for various activities such as TV viewing and advertising exposure. It is important
that parents be aware of the amount of advertising exposure their children receive and its impact on their food
preferences. Parents should also understand the importance of refraining from watching TV during meals,
removing TV from children’s bedrooms, and generally limiting their children’s exposure to TV. One
recommendation offered by IOM involves partnerships between government and the private sector to
implement social marketing efforts targeted at educating and helping parents build skills to select and prepare
6
healthful foods and beverages for their children. Teaching parents about communicating on consumer matters
and media literacy may also benefit their children to make more informed eating choices.
References
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J. Kaiser Family Foundation, 2010. Available at: http:www.kff.org/entmedia/upload/8010.pdf. Accessed May 15, 2013.
2. Food for Thought. Television Food Advertising to Children in the United States. A Kaiser Family Foundation Report. The Henry J. Kaiser
Family Foundation, March 2007. Available at: http://kff.org/other/food-for-thought-television-food-advertising-to/. Accessed May 15, 2013.
3. Rudd Center for Food Policy & Obesity. Trends in Television Food Advertising: Progress in Reducing Unhealthy Marketing to Young
People? 2010. Available at: http://www.yaleruddcenter.org/resources/upload/docs/what/reports/RuddRep.... Accessed May 15, 2013.
4. Harris JL, Bargh JA. Television viewing and unhealthy diet: implications for children and media interventions. Health Commun.
2009;24(7):660-673.
5. 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? J Nutr Educ Behav. 2002;34(6):310-315.
6. Institute of Medicine, Committee on Food Marketing and the Diets of Children and Youth. Food marketing to children and youth: Threat or
opportunity, 2006.
7. Robinson TN, Borzekowski DL, Matheson DM, Kraemer HC. Effects of fast food branding on young children's taste preferences. Arch
Pediatr Adolesc Med. 2007;161(8):792-797.
8. Dixon HG, Scully ML, Wakefield MA, White VM, Crawford DA. The effects of television advertisements for junk food versus nutritious food on
children's food attitudes and preferences. Soc Sci Med. 2007;65(7):1311-1323.
9. Story M, French S. Food Advertising and Marketing Directed at Children and Adolescents in the US. Int J Behav Nutr Phys Act. 2004;1(1):3.
10. Lapierre MA, Vaala SE, Linebarger DL. Influence of licensed spokescharacters and health cues on children's ratings of cereal taste. Arch
Pediatr Adolesc Med. 2011;165(3):229-234.

11. Lumeng J. Cartoon characters on food packages influence taste and snack preferences in young children. J Pediatr. 2011;158(1):170-171.
12. Linn SE. Food marketing to children in the context of a marketing maelstrom. J Public Health Policy. 2004;25(3-4):367-378.
13. Federal Trade Commission. Marketing Food to Children and Adolescents: A Review of Industry Expenditures, Activities, and Self-
Regulation, 2008. Available at: http://www.ftc.gov/os/2008/07/P064504foodmktingreport.pdf. Accessed August, 25 2007.
14. Powell LM, Szczypka G, Chaloupka FJ. Exposure to food advertising on television among US children. Arch Pediatr Adolesc Med.
2007;161(6):553-560.
15. Halford JC, Boyland EJ, Hughes G, Oliveira LP, Dovey TM. Beyond-brand effect of television (TV) food advertisements/commercials on
caloric intake and food choice of 5-7-year-old children. Appetite. 2007;49(1):263-267.
16. Birch LL. Development of food preferences. Annu Rev Nutr. 1999;19:41-62.
17. Lanfer A, Knof K, Barba G, et al. Taste preferences in association with dietary habits and weight status in European children: results from
the IDEFICS study. Int J Obes (Lond). 2011.
18. Chang H, Nayga Jr RM. Television Viewing, Fast-Food Consumption, and Children's Obesity. Contemporary Economic Policy.
2009;27(3):293.
19. Chamberlain LJ, Wang Y, Robinson TN. Does children's screen time predict requests for advertised products? Cross-sectional and
prospective analyses. Arch Pediatr Adolesc Med. 2006;160(4):363-368.
20. Buijzen M, Schuurman J, Bomhof E. Associations between children's television advertising exposure and their food consumption patterns: a
household diary-survey study. Appetite. 2008;50(2-3):231-239.
21. Andreyeva T, Kelly IR, Harris JL. Exposure to food advertising on television: associations with children's fast food and soft drink
consumption and obesity. Econ Hum Biol. 2011;9(3):221-233.
22. Wiecha JL, Peterson KE, Ludwig DS, Kim J, Sobol A, Gortmaker SL. When children eat what they watch: impact of television viewing on
dietary intake in youth. Arch Pediatr Adolesc Med. 2006;160(4):436-442.
23. Barr-Anderson DJ, Larson NI, Nelson MC, Neumark-Sztainer D, Story M. Does television viewing predict dietary intake five years later in
high school students and young adults? Int J Behav Nutr Phys Act. 2009;6:7.
24. Dovey TM, Taylor L, Stow R, Boyland EJ, Halford JC. Responsiveness to healthy television (TV) food advertisements/commercials is only
evident in children under the age of seven with low food neophobia. Appetite. 2011;56(2):440-446.
25. Halford JC, Boyland EJ, Hughes GM, Stacey L, McKean S, Dovey TM. Beyond-brand effect of television food advertisements on food choice
in children: the effects of weight status. Public Health Nutr. 2008;11(9):897-904.
26. Grier SA, Mensinger J, Huang SH, Kumanyika SK, Stettler N. Fast-Food marketing and children's fast-food consumption: Exploring parents'
influences in an ethnically diverse sample. American Marketing Associations. 2007;26(2):221.
27. Outley CW, Taddese A. A content analysis of health and physical activity messages marketed to African American children during after-
school television programming. Arch Pediatr Adolesc Med. 2006;160(4):432-435.
28. Powell LM, Szczypka G, Chaloupka FJ. Trends in exposure to television food advertisements among children and adolescents in the United
States. Arch Pediatr Adolesc Med. 2010;164(9):794-802.
29. Henderson VR, Kelly B. Food advertising in the age of obesity: content analysis of food advertising on general market and African American
television. J Nutr Educ Behav. 2005;37(4):191-196.
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foods in the supermarket. Public Health Nutr. 2010;13(3):409-417.
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children and adolescents, 1988-2004. Pediatrics. 2008;121(6):e1604-14.
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Public Health Nutr. 2006;9(2):244-250.
33. Chou SY, Rashad I, Grossman M. Fast-food restaurants advertising on television and its influence on childhood obesity. Journal of Low and
Economics. 2008;51(4):599.
34. Goris JM, Petersen S, Stamatakis E, Veerman JL. Television food advertising and the prevalence of childhood overweight and obesity: a
multicountry comparison. Public Health Nutr. 2010;13(7):1003-1012.
35. Veerman JL, Van Beeck EF, Barendregt JJ, Mackenbach JP. By how much would limiting TV food advertising reduce childhood obesity?
Eur J Public Health. 2009;19(4):365-369.
36. Buijzen M. The effectiveness of parental communication in modifying the relation between food advertising and children's consumption

behaviour. Br J Dev Psychol. 2009;27(Pt 1):105-121.
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New Haven, CT, 2011. Available at http://www.yaleruddcenter.org/resources/upload/docs/what/reports/RuddRep.... Accessed May 15, 2013.
40. Kunkel D, McKinley C, Wright P. The Impact of Industry Self-Regulation on the Nutritional Quality of Foods Advertised on Television to
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Benefits-of-Limiting-TV.aspx. Accessed May 15, 2013.

Eating Behaviour in Studies of Child
Growth, Development and Health –
Measure Precisely, Early and in Context:
Commentary on Ramsay, Liu & Stein, Black
& Hurley, Milnes, Piazza & Carrol,
Llewellyn & Wardle, and Arcan, Bruening
and Story
Myles S. Faith, PhD
Gillings School of Global Public Health, University of North Carolina at Chapel Hill, USA
September 2013
Introduction
Eating is essential for healthy growth and development. Along with physical activity, eating is the major
behavioural conduit through which energy balance is regulated, through which food choices are made, and
around which numerous interactions with family members and peers occur. Children’s food choices and diet
composition influence health status during development and, potentially, later life. Perhaps there is no better
example of this than that of pediatric obesity, which tracks through adolescence and into adulthood and predicts
a number of health disorders. For all these reasons, it is imperative that clinical guidelines and policy
recommendations intended to foster healthy eating by children be guided by rigorous scientific studies and
methodology. Quality measurement is fundamental to this endeavour and, as noted below, is a focal point of
1-6
the papers in this chapter.
1-6
The papers reviewed in this section address a variety of topics related to the development of feeding and
eating patterns throughout development, starting in infancy. The papers address biological and environmental
drivers of refined eating phenotypes within “normal” populations as well as more specialized patient samples
1-6
(e.g., feeding disorders). They present some of the strongest scientific innovations in the pediatric ingestive
behaviour fields, while highlighting real-world clinical and policy implications where real lives are touched. This
is where the “rubber meets the road” of real-world eating behaviour.
1-6
A cross-cutting, if not unifying theme, across these papers is the critical role of measurement in driving
scientific advances. Armed with quality measurement, new insights have emerged which ultimately may better
1-6
inform policy. Three conclusions can be drawn upon review of these papers, with respect to measurement:

(1) Measure eating behaviour precisely; (2) Measure eating behaviour early; and (3) Measure eating behaviour
in context. These are discussed next.
Research and Conclusions
Measure eating behaviour precisely

1-6
The contributions in this chapter reveal insights that can be gleaned by using quality assessment tools that
capture precise, refined dimensions of child eating behaviour. For example, as reviewed by Llewellyn and
5 7
Wardle, development of the Child Eating Behavior Questionnaire over the past decade has yielded critical
insights into the development of children’s “food responsiveness” and “satiety awareness” – both of which are
8,9
linked to childhood obesity. The tool has been used internationally and allowed for replication of findings
across diverse populations. This suggests novel targets for intervention (e.g., training children to recognize
10 4
hunger/fullness cues) that, with rare exception, have not been explored to date. Milnes et al.’s contribution
illustrates how researchers can quantify specific parenting strategies in the context of pediatric feeding
disorders (e.g., coaxing, reprimanding) and how these may impact on specific child eating patterns (e.g., bites
1
of food, food refusal). Ramsay’s contribution illustrates how inefficient sucking, assessed by polygraph among
young infants with gastroesophageal reflux, predicted poorer feeding skills and readiness for solid foods.
11,12
Interestingly, there is other evidence that voracious sucking by infants is a risk factor for childhood obesity.
These examples underscore a point that is implicit throughout these contributions – but which needs explicit
highlighting – that precise measurement has been essential for these scientific advances and will be critical to
the next generation of discovery.
Measure eating behaviour early

1-6
As illustrated in this chapter, eating behaviours can be measured reliably at earlier ages including infancy.
13-15 5
This is illustrated by the Baby Eating Behaviour Questionnaire, discussed by Llewellyn and Wardle, the
3
subscales of which may reflect early markers for obesity risk. As Black et al. discuss, excess caloric intake
during toddlerhood has been documented in population-based research, along with insufficient intake of fruits
1
and vegetables and essential micronutrients. Ramsay’s contribution raises the topic of temperament and to
what extent it might impact on feeding behaviour. Interestingly, there is emerging evidence that a “difficult”
16
infant temperament in the first years of life may be risk factor for childhood obesity. With the development of
new tools to assess eating behaviour in early life, researchers will be able to explore new causal models for
(un)healthy growth and development.
Measure eating behaviour in context

1-6
The contributions to this chapter reveal that eating behaviour occurs in a multi-level context. This context
includes individual-level factors (e.g., genetics; temperament), as well as family-level factors (e.g., parental
feeding practices; family relations) and societal/cultural factors (e.g., television commercials; laws regulating
17,18
advertisements). This framework is consistent with the “socio-ecological model” and has been endorsed by
19
an American Heart Association task force on the promotion of healthy eating. Understanding multi-level
20
systems is scientifically challenging yet a pressing research and policy need. This includes research linking
5
genetics to individual child eating behaviour (as illustrated by Llewellyn and Wardle ) as well as individual child

6
food preferences and intake to advertising policy (as illustrated by Arcan et al. ).
What’s missing?
1-6
The contributions to this chapter reveal the importance of measurement and its potential to provide refined
characterizations of infant/toddler/child eating dimensions. This is profoundly important. Armed with these
assessment tools, one of the greatest research needs can be better addressed: Better understanding the
children for whom, and conditions under which, specific eating behaviours will promote or protect against
disease onset. Answering these questions will require birth cohorts that are tracked across the development
12 21
and – ideally – into adulthood. For example, are refined traits such as sucking intensity, food neophobia,
8 22
food responsiveness, and negative affect when eating causally related to childhood obesity onset? If so, for
whom and under what environmental conditions are these associations intensified or attenuated?
Development and Policy Implications
The authors provide thoughtful discussions regarding the policy implications for their respective topics. The
findings, collectively, suggest an important implication for policy-level changes striving to modify child eating
behaviour: It is unclear that all children necessarily will respond the same way to a given intervention. Whatever
the policy may be (e.g., providing fruits and vegetables to schools; limiting the portion sizes of sugary
beverages), one potentially should anticipate individual differences that drive non-uniform responses to the
same policy. These individual differences might, conceivably, be related to factors such food responsiveness or
satiety awareness (which may have a sizable genetic loading), temperament, family interactions, neighborhood
characteristics, or other unknown factors that influence how children eat. Being positioned to assess individual
differences may help to reveal the conditions under which, and children for whom, certain policy changes will be
more/less effective in fostering a healthier diet.
Finally, given the many factors that potentially impact on child eating behaviour, experimental studies that allow
for strong causal inference are needed to guide policy development for healthy eating and obesity prevention.
Indeed, laboratory studies and quasi-experimental designs can be enormously informative in this regard. This is
23
illustrated by a recent review by Epstein et al. which examined the impact of taxes and subsidies on food
purchases. The review focused on studies using experimental designs, including laboratory-based
investigations.
References
1. Ramsay M. Feeding skill, appetite and feeding behaviours of infants and young children and their impact on growth and psychosocial
development. Faith MS, topic ed. In: Tremblay RE, Boivin M, Peters RDeV, eds. Encyclopedia on Early Childhood Development [online].
Montreal, Quebec: Centre of Excellence for Early Childhood Development and Strategic Knowledge Cluster on Early Child Development;
2013:1-8. Available at: http://www.child-encyclopedia.com/documents/RamsayANGxp2.pdf. Accessed May 15, 2013.
2. Liu YH, Stein MT. Feeding behaviour of infants and young children and its impact on child psychosocial and emotional development. In:
Tremblay RE, Barr RG, Peters RDeV, eds. Encyclopedia on Early Childhood Development [online]. Montreal, Quebec: Centre of Excellence
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15, 2013.
3. Black MM, Hurley KM. Helping children develop healthy eating habits. Faith MS, topic ed. In: Tremblay RE, Boivin M, Peters RDeV, eds.
Encyclopedia on Early Childhood Development [online]. Montreal, Quebec: Centre of Excellence for Early Childhood Development and
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HurleyANGxp3-Eating.pdf. Accessed May 15, 2013.

4. Milnes SM, Piazza CC, Carroll TA. Assessment and treatment of pediatric feeding disorders. Faith MS, topic ed. In: Tremblay RE, Boivin M,
Peters RDeV, eds. Encyclopedia on Early Childhood Development [online]. Montreal, Quebec: Centre of Excellence for Early Childhood
Development and Strategic Knowledge Cluster on Early Child Development; 2013:1-5. Available at: http://www.child-
encyclopedia.com/documents/Milnes-Piazza-CarrollANGxp2.pdf. Accessed May 15, 2013.
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Child nutrition

Updated: September 2013

Helping Children Develop Healthy Eating Habits 16

Assessment and Treatment of Pediatric Feeding Disorders 23

Genetic Influences on Child Eating Behaviour 27

Television (TV) and TV Advertisement Influences on Children’s Eating Behaviour 33

Eating Behaviour in Studies of Child Growth, Development and Health – Measure 40

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What can be done?

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Key Research Questions

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Implications for Policy and Services

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9. Hamilton AB, Zeltzer LK. Visceral pain in infants. J Pediatr.1994;125:S95-102.

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Key Research Questions

Recent Research Results

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Implications for Policy and Service

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Key Research Questions

Recent Research Results

Attachment and eating

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The caregiver-child context of feeding

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

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Research Results and Conclusions

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Problems and Research Context

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Key Research Questions

1. Is eating behaviour heritable?

2. Which genes influence eating behaviour?

3. Do weight-related genes influence weight via eating behaviour?

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Genetic influences on child eating behaviour

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Implications for Parents, Services and Policy

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