Pressuring and restrictive feeding styles influence infant feeding and size among a low-income African-American sample

A randomized controlled trial to test the efficacy of a brief Triple P discussion group to increase healthy feeding practices and reduce risk factors for infant obesity

OBJECTIVE

Test the efficacy of a brief 2-hr parenting intervention in increasing protective factors against and reducing risk factors for infant obesity.

METHOD

A 2 (Baby Healthy Living Triple P vs. care-as-usual) × 3 (baseline, postintervention, 6-month follow-up) design was used. Eighty-two parents of 4- to 18-month-old infants meeting at least two risk factors for early childhood obesity (e.g., parent/child overweight, low education level) were randomized to intervention (n = 42) or control group (n = 40). Parents questionnaires and child weight status was measured.

RESULTS

Results showed an intervention effect on a primary outcome, early feeding practices (restrictive: d = 0.44, 95% CI [-0.01,0.88], pressuring: d = 0.11, 95% CI [-0.32,0.54], nonresponsive behaviors: (d = 0.32, 95% CI [-0.11,0.75]), and on a secondary outcome, feeding beliefs (d = 0.29, 95% CI [-0.14,0.73]). No beneficial impact was found on other primary outcomes (responsiveness in feeding: quantity d = 0.50, 95% CI [-0.03,1.03]) and nutritive d = 0.52, 95% CI [-0.03,1.07], mealtime environment: d = 0.35, 95% CI [-0.78,0.08], self-efficacy in responsive feeding: d = 0.21, 95% CI [-0.22,0.64]), or secondary outcomes (parental self-efficacy: d = 0.08, 95% CI [-0.50,0.35]), parent emotional eating (d = 0.01, 95% CI [-0.43,0.43]), food restraint (d = 0.42, 95% CI [-0.85,0.02]), and body satisfaction (d = 0.01, 95% CI [-0.43,0.43]) and child weight status (d = 0.11, 95% CI [-0.54,0.32]).

CONCLUSIONS

Promising though limited support was demonstrated for a brief, low-intensity program to help parents in the prevention of obesity for infants at risk.

Child and Maternal Factors Associated with Feeding Practices in Children with Poor Growth

The development of adequate growth and healthy eating behaviors depends on nutritious food and responsive feeding practices. Our study examined (1) the relationship between maternal concern about child weight or perceived feeding difficulties and their feeding practices, and (2) the moderating role of child temperament and maternal mental health on their feeding practices. A cross-sessional study included mother-child dyads (n = 98) from a tertiary growth and feeding clinic. Children had a mean age of 12.7 ± 5.0 months and a mean weight-for-age z-score of -2.0 ± 1.3. Responsive and controlling feeding practices were measured with the Infant Feeding Styles Questionnaire. Spearman correlation and moderation analysis were performed. Maternal concern about child weight and perceived feeding difficulties were negatively correlated with responsive feeding (r = -0.40, -0.48, p < 0.001). A greater concern about child weight or perceived feeding difficulties was associated with greater use of pressure feeding practices when effortful control was low (B = 0.49, t = 2.47, p = 0.01; B = -0.27, p = 0.008). Maternal anxiety had a significant moderation effect on the relationship between feeding difficulty and pressure feeding (B = -0.04, p = 0.009). Higher maternal concern about child weight and perceived feeding difficulties were associated with less responsive satiety feeding beliefs and behaviors. Both child effortful control and maternal anxiety influenced the relationship between weight and feeding concerns and the use of pressure feeding practices.

Sequential mediation of early temperament and eating behaviors in the pathways from feeding practices to childhood overweight and obesity

Introduction

Childhood eating behaviors and temperament may have important implication for constructing the pathways from maternal feeding practices to childhood overweight and obesity (OW/OB). Examining multiple feeding styles simultaneously to childhood OW/OB is critical through the mediators of early childhood temperament and eating behaviors.

Methods

This cross-sectional study recruited mothers mainly responsible for child care from two hospitals and two healthcare centers in eastern China. Sociodemographic characteristics, and data from the Infant Feeding Style Questionnaire (IFSQ), the short form of Children Behavior Questionnaire [Revised (IBQ-RSF)], and the Child Eating Behavior Questionnaire for toddler (CEBQ-T) were collected. Weight and recumbent length were measured to calculate the age- and sex-specific body mass index (BMI) z-scores (BMIz). The structural equation modeling (SEM) approach was used to examine direct and indirect pathways from five maternal feeding styles to childhood OW/OB through temperament and eating behaviors.

Results

A total of 486 children were recruited, 73 (15.02%) children were OW/OB; the age of the children was 14.55 (SD = 5.14) months, and the age of the mothers was 29.90 (SD = 3.63) years. The responsive feeding exerted significant direct (β = -0.098), indirect (β = -0.136) and total (β = -0.234) effects on childhood OW/OB. Restrictive feeding had significant direct (β = 0.222), indirect (β = 0.102) and total (β = 0.324) effects on childhood OW/OB. Indulgent feeding had significant direct (β = 0.220), indirect (β = 0.063), and total (β = 0.283) effects on childhood OW/OB. Pressuring feeding had significant direct (β = -0.116), indirect (β = -0.096) and total (β = -0.212) effects on childhood OW/OB.

Discussion

There was a direct effect of feeding practices on childhood OW/OB; feeding practices indirectly predicted childhood OW/OB through temperament and eating behaviors in children aged 6-23 months. This study could help governments agencies, policymakers, and healthcare workers to establish optimal intervention programs targeting feeding practices through childhood eating behaviors and temperament to prevent childhood OW/OB.

Parental food selection questionnaire - Infant version

PURPOSE

Complementary feeding practices (CFPs) are associated with health outcomes (e.g., obesity and food allergies). Understanding how parents select foods for their infant is limited. This study's purpose was to develop a psychometrically sound measure of parents' food selection motives for their infant during the complementary feeding period.

METHODS

Development and testing of the Parental Food Slection Questionnaire-Infant Version (PFSQ-I) occurred in three phases. English-speaking, U.S. mothers of healthy infants, aged 6-19 months old participated in a semi-structured, face-to-face interview (Phase 1) or a web-based survey (Phases 2 & 3). Phase 1 was a qualitative study of maternal beliefs and motives surrounding complementary feeding. Phase 2 involved adaptation and exploratory factor analysis of the original Food Choice Questionnaire (Steptoe et al., 1995). Phase 3 involved validity testing of the relationships among PFSQ-I factors and CFPs (timing/type of complementary food introduction, frequency of feeding method, usual texture intake, and allergenic food introduction) using bivariate analyses, and multiple linear and logistic regression analyses.

RESULTS

Mean maternal age was 30.4 years and infant age was 14.1 months (n = 381). The final structure of the PFSQ-I included 30 items and 7 factors: Behavioral Influence, Health Promotion, Ingredients, Affordability, Sensory Appeal, Convenience, and Perceived Threats (Cronbach's α = 0.68-0.83). Associations of factors with CFPs supported construct validity.

DISCUSSION

The PFSQ-I demonstrated strong initial psychometric properties in a sample of mothers from the U.S. Mothers who rated Behavioral Influence as more important were more likely to report suboptimal CFPs (e.g., earlier than recommended complementary food introduction, delayed allergenic food introduction, and prolonged use of spoon-feeding). Additional psychometric testing in a larger, more heterogenous sample is needed, along with examination of relationships between PFSQ-I factors and health outcomes.

Capacity for Regulation of Energy Intake in Infancy

Importance

The capacity for regulation of energy intake (REI) to match energy needs is thought to contribute to differences in weight gain, and preventing excess infant weight gain is a priority.

Objective

To determine capacity for REI across infancy.

Design, Setting, and Participants

For this cohort study, a convenience sample of mother-infant dyads was recruited from the community in Michigan between 2015 and 2019. Inclusion criteria were healthy, full-term infants with weight appropriate for gestational age; biological mothers who were 18 years or older, English speaking, and a legal and custodial guardian; and infant having had consumed 2 oz or more in 1 feeding from an artificial nipple at least once per week. Infants were followed in the home setting with staff support for up to 12 months.

Interventions

Mother-infant dyads participated at infant age 1, 2.5, 5, 7, 10, and 12 months. In the intervention condition, mothers offered a feeding every hour for 6 hours. In the control condition, mothers fed infants as they typically would for 6 hours. Intake was recorded and kilocalories calculated.

Main Outcomes and Measures

Capacity for REI was indexed as the difference in intake in kilocalories per kilogram of body weight (intervention minus control condition); a value of 0 indicated perfect REI. Maternal and infant characteristics were obtained by questionnaire, and anthropometry was measured. Using multiple imputation, the intercept and slope for difference in kilocalories per kilogram across the 6 age points were estimated using mixed models accounting for repeated measures within participants. Statistical analyses were conducted between September 2021 and February 2023.

Results

The sample included 175 infants (87 [49.71%] female, 88 [50.29%] male; 494 pairs of intervention and control conditions and 4630 feedings). The mean (SD) 12-month weight-for-age z score was 0.1 (0.8). Mean (SD) gestational age as 39.55 (1.05) weeks, and mean (SD) birth weight was 3.43 (0.41) kg. Mean (SD) breastfeeding duration for those who reported stopping by 12 months was 17.83 (12.03) weeks. As designed, the intervention (compared with control) condition included more feedings at shorter intervals. After collapsing the data across age points in a mixed model accounting for repeated measures within participants, the REI estimate at 1 month differed from 0. On average, infants ate 5.21 kcal/kg (95% CI, 2.89-7.54 kcal/kg) more in the frequent feeding intervention condition than in the ad lib feeding control condition. This difference did not significantly change over 12 months of infancy (REI slope = -0.01 kcal/kg per month; 95% CI, -0.02 to 0.03 kcal/kg per month).

Conclusions and Relevance

The study's findings suggested that, on average, when offered more frequent feedings, healthy, full-term infants may overeat. The results provide support for responsive feeding as a strategy for preventing excess infant weight gain.

Confirmatory factor analysis of the infant feeding styles questionnaire in infant and toddler child care teachers

Early childhood is a critical time of development. Caregiver feeding style, including of child care providers, has been implicated in influencing children's food preferences and obesity. A better understanding of the determinants of child care providers' feeding styles is important as children increasingly receive daily care and nutrition in child care centers. Valid instruments to measure provider feeding styles specifically for infants are needed. This study's objective was to validate, for use with child care providers, the Infant Feeding Styles Questionnaire (IFSQ), an instrument originally designed for parents of infants and toddlers. Study data came from the Baby Nutrition and Physical Activity Self-Assessment for Child Care (Baby NAP SACC) study, a cluster randomized trial, designed to evaluate the efficacy of a six-month-long obesity prevention intervention in child care centers. The IFSQ was administered at baseline and follow-up to infant and toddler teacher participants (n = 244). Scores for baseline IFSQ teacher responses (n = 219) were calculated for the 13 sub-constructs across the five feeding styles. We tested reliability with Cronbach's alpha coefficients and performed confirmatory factor analysis to examine factor loadings and goodness of fit characteristics, modifying constructs to achieve best fit. Reliability coefficients ranged from 0.42 to 0.82 for all sub-constructs. Goodness of fit indices for the final model ranged from: root mean square error of approximation (RMSEA) 0.000-0.082; comparative fit index (CFI) 0.943-1.000; Tucker-Lewis index (TLI) 0.906-1.000; and standardized root mean squared error (SRMR) 0.006-0.130. In a sample of racially diverse infant and toddler child care teachers, final models of the laissez-faire, pressuring, and responsive constructs and the restrictive-diet quality sub-construct performed well. Overall model fit was poor for the indulgence construct, but good for solely its corresponding belief items.

Comparison of mothers' perceptions of hunger cues in 3-month-old infant under different feeding methods

BACKGROUND

Mothers' perception of infant hunger cues is a critical content of responsive feeding, which is central to the promotion of early childhood development. However, only a few studies have examined responsive feeding in China, especially lacking the studies on perceptions of infant hunger cues. Consider the cultural differences, the aim of this study was to describe the perceptions of infant hunger cues of Chinese mothers for infants aged 3 months, and explore the relationship between maternal perceptions of infant hunger cues and different feeding methods.

METHODS

A cross-sectional study was conducted with a sample of 326 mothers of healthy 3-month-old infants, including 188 exclusive breastfeeding (EBF) mothers and 138 formula feeding (FF) mothers. It was implemented in four provincial and municipal maternal and child health hospitals. The mothers' perceptions of infant hunger cues were surveyed by self-reporting questionnaires. Chi-square tests and logistic analysis were applied to analyze the differences in maternal perceptions of infant hunger cues, including the number of hunger cues and the specific cues, between EBF group and FF group by controlling sociodemographic variables and the daily nursing indicators.

RESULTS

We found that a higher proportion of EBF mothers could perceive multiple hunger cues (≥ 2) than FF mothers (66.5% vs.55.1%). For specific cues, the EBF mothers had higher perceptions of infant's "hand sucking" (67.6% vs. 53.6%) and "moving head frantically from side to side" (34.6% vs. 23.9%), all p < 0.05. Regression analysis revealed that EBF might support mothers to perceive infant hunger cues than FF mothers, with the number of infant hunger cues (OR = 1.70, 95% CI: 1.01-2.85), "hand sucking" (OR = 1.72, 95% CI: 1.04-2.87), "moving head frantically from side to side" (OR = 2.07, 95% CI: 1.19-3.62). The number of infant hunger cues perceived by mothers was also associated with their educational level and family structure.

CONCLUSION

EBF mothers of 3-month-old infants may be more likely to perceive infant hunger cues than FF mothers in China. It is necessary to increase the health education about infant hunger and satiety cues to caregivers in China, especially among mothers with lower education levels, mothers living in nuclear families, and FF mothers.

Cross-sectional and prospective associations between household socioeconomic resources, appetite traits, and body size among Samoan infants

In high-income countries, household socioeconomic resources (as measured by education, occupation, income, and/or household assets) and childhood obesity risk tend to be negatively associated. This association may arise in part because children from households with fewer resources are exposed to obesogenic environments that shape appetite trait development. In contrast, many low- and middle-income countries (LMICs) exhibit a positive association between socioeconomic resources and child body size. There is less evidence from LMIC settings about when during development this association emerges and whether appetite traits play a mediatory role. To explore these questions, we examined cross-sectional and longitudinal associations between socioeconomic resources, appetite traits, and body size among infants in Samoa, an LMIC in Oceania. Data were from the Foafoaga O le Ola prospective birth cohort of 160 mother-infant dyads. Appetite traits were characterized using the Baby and Child Eating Behavior Questionnaires and household socioeconomic resources were quantified using an asset-based measure. While infant body size and household socioeconomic resources were positively associated in both cross-sectional and prospective analyses, we found no evidence that appetite traits mediate this relationship. These results suggest that other aspects of the food environment, such as food security and feeding style, may explain the positive association between socioeconomic resources and body size observed in many LMICs.

The association between parents' stress and parental feeding practices and feeding styles: Systematic review and meta-analysis of observational studies

In the extended UNICEF framework of early childhood nutrition, parents' stress is associated with parental feeding style. However, no comprehensive review has examined the association between parents' stress and feeding styles and practices. The objective of our review was to synthesise the current literature examining the association between parents' stress and their feeding practices and/or styles, among parents of children ≤ 5 years old. We searched; MEDLINE, EMBASE, PSYCHINFO and CINAHL from 2019 to 2021. Two investigators independently extracted relevant data and assessed the study quality and the certainty of evidence. Data were pooled using generic inverse variance with fixed effects (<5 comparisons) or random effects (≥5 comparisons) and expressed as correlation coefficients with 95% confidence intervals (CI). Between study heterogeneity was assessed using Cochran's Q and quantified with I2 . We identified 6 longitudinal and 11 cross-sectional studies, of which 4 studies provided sufficient data to be pooled. A very small correlation between general stress and restrictive feeding practices was observed (r = 0.06 [95% CI: 0.01-0.12]; no substantial heterogeneity (I2  = 0.00%, PQ  < 0.85, very low certainty). No correlation between general stress and feeding pressure was identified (r = 0.06 [95% CI: -0.02 to 0.15]). Results showed that both general and parenting stress were associated with suboptimal breastfeeding practices and unresponsive feeding styles. Conclusion: This study demonstrated a low-to-moderate quality of literature for the inclusion of parents' stress in the extended UNICEF care model of child nutrition. Future research needs to explore this relationship longitudinally and in ethnic diverse populations to inform tailored interventions that promote responsive feeding practices.

The Longitudinal Relation between Infant Feeding Styles and Growth Trajectories among Families from Low-Income Households

BACKGROUND

Parental feeding styles, including the emotional environment parents create to modify a child's eating behaviors, have been associated with measures of adiposity in cross-sectional studies. The longitudinal relation between parental feeding styles in early infancy and adiposity in later infancy/toddlerhood are scant and have shown mixed results, particularly in families from low-income households.

OBJECTIVES

This study examined the relation between parental feeding styles and infant BMI z-score trajectories between 6 and 18 mo in families from low-income households.

METHODS

Parent-infant dyads were recruited during the infant's 6-, 9-, or 12-mo well-child visit. Feeding styles were assessed using the Infant Feeding Style Questionnaire (IFSQ). Infant anthropometrics from birth through 18 mo were extracted from the electronic medical record. BMI z-score slopes were estimated for each infant between 0-6 mo and 6-18 mo. Associations between feeding styles and BMI z-score slopes were examined using mixed models controlling for demographic, clinical, and feeding covariates.

RESULTS

The final analytic sample included 198 dyads (69% Black; median infant age: 9.0 mo; IQR: 6.8-10.3 mo). The predominant parent feeding styles included the following: laissez-faire (30%), restrictive (28%), responsive (23%), and pressuring (19%). In adjusted models, the predominant feeding style at enrollment was associated with the BMI z-score slope between 6 and 18 mo, with the responsive feeding style exhibiting a steeper increase in BMI z-score than other feeding styles. Infant feeding style was not associated with BMI z-score slope between birth and 6 mo of age. Infants of parents who exhibited restrictive feeding styles were more likely to have a BMI ≥85th percentile at their last measurement.

CONCLUSIONS

The predominant parent feeding style during infancy in a low-income population was associated with infant BMI z-score between 6 and 18 mo of age, but not earlier. Further studies are needed to better understand how predictive factors collectively contribute to BMI increase in the first 2 y.

Complementary Feeding Caregivers' Practices and Growth, Risk of Overweight/Obesity, and Other Non-Communicable Diseases: A Systematic Review and Meta-Analysis

Several institutions propose responsive feeding (RF) as the caregivers' relational standard when nurturing a child, from breast/formula feeding onwards. Previous systematic reviews (SRs) on caregivers' feeding practices (CFPs) have included studies on populations from countries with different cultures, rates of malnutrition, and incomes, whereas this SR compares different CFPs only in healthy children (4-24 months) from industrialized countries. Clinical questions were about the influence of different CFPs on several important outcomes, namely growth, overweight/obesity, risk of choking, dental caries, type 2 diabetes (DM2), and hypertension. The literature review does not support any Baby Led Weaning's or Baby-Led Introduction to SolidS' (BLISS) positive influence on children's weight-length gain, nor their preventive effect on future overweight/obesity. RF-CFPs can result in adequate weight gain and a lower incidence of overweight/obesity during the first two years of life, whereas restrictive styles and coercive styles, two kinds of non-RF in CF, can have a negative effect, favoring excess weight and lower weight, respectively. Choking risk: failure to supervise a child's meals by an adult represents the most important risk factor; no cause-effect relation between BLW/BLISS/RF/NRCF and choking could be found. Risks of DM2, hypertension, and caries: different CFPs cannot be considered as a risky or preventive factor for developing these conditions later in life.

Infant appetite and weight gain in early infancy: Moderating effects of controlling feeding styles

Excessive infant weight gain is a strong predictor of later obesity. While controlling feeding has been linked to negative weight outcomes, research has not considered associations between infant appetite and maternal feeding simultaneously in relation to infant weight. This longitudinal study examined infant food responsiveness and slowness in eating as predictors of infant weight outcomes and tested controlling feeding styles (restrictive and pressuring) as moderators. Data came from a diverse sample of mothers and their infants participating in an ongoing longitudinal study. Mothers (n = 159) reported infant appetite and feeding styles at 2 postnatal timepoints (2-month visits and 6-month visits). The infant weight outcomes included change in weight-for-age z-scores (WAZ-change) and rapid weight gain (RIWG; WAZ-change ≥ 0.67 SD) from birth to the second postnatal visit. Data were analyzed using hierarchical multiple and logistic regressions, controlling for birthweight, gestational age, maternal race/ethnicity, feeding mode, and residing with an intimate partner. Over 25% of infants exhibited RIWG. Greater infant food responsiveness predicted both greater infant weight gain and RIWG status. Infant food responsiveness and slowness in eating interacted with controlling feeding styles in a unique way. Infants with higher food responsiveness whose mothers were less restrictive had greater weight gain (b = 0.61, p < 0.001) and increased probability of RIWG (b = 2.71, p < 0.01) than infants with more restrictive mothers. Higher slowness in eating was associated with a lower RIWG probability among infants of mothers with lower pressuring feeding (b = -1.86, p < 0.05). For infants with a large appetite, some level of restrictive feeding may be beneficial for preventing excessive weight gain while pressuring may exacerbate the positive association between faster eating and RIWG.

A Study on Online Intervention for Early Childhood Eating Disorders during COVID-19

Eating disorders are among the most common clinical manifestations in children, and they are frequently connected with maternal psychopathological risk, internalizing/externalizing problems in children, and poor quality of mother-child feeding exchanges. During the COVID-19 lockdown, in person assessment and intervention were impeded due to the indications of maintaining interpersonal distancing and by limits to travel. Therefore, web-based methods were adopted to meet patients' needs. In this study N = 278 participants completed the SCL-90/R and the CBCL to examine the psychopathological symptoms of mothers and children (age of the children = 24 months); moreover, the dyads were video-recorded during feeding and followed an online video-feedback based intervention. Maternal emotional state, interactive conflict, food refusal in children, and dyadic affective state all improved considerably, as did offspring internalizing/externalizing problems and mothers' depression, anxiety, and obsession-compulsion symptoms. This study showed that video-feedback web-based intervention might be employed successfully to yield considerable beneficial effects.

Racial/ethnic differences in maternal feeding practices and beliefs at 6 months postpartum

OBJECTIVE

To examine racial/ethnic differences in maternal feeding practices and beliefs in a sample of low-income smoke-exposed women.

DESIGN

Cross-sectional analysis using data collected during a randomised control trial. Maternal feeding practices and beliefs were assessed using the Infant Feeding Questionnaire (IFQ), which was administered at 6 months postpartum. ANOVA was used to examine differences in IFQ items by race/ethnicity, while multivariable linear regression models were used to examine differences in IFQ factor scores by race/ethnicity adjusting for potential confounders.

SETTING

Participants were recruited from prenatal clinics.

PARTICIPANTS

343 women (39 % non-Hispanic White, 28 % Hispanic/Latina, 13 % Black, and 20 % other).

RESULTS

Racial/ethnic minority mothers were more likely than non-Hispanic White mothers to put cereal in their infant's bottle so that the infant would stay full longer (P = 0·032), state their infant wanted more than just formula or breast milk prior to 4 months (P = 0·019), allow their infant to eat whenever he/she wanted (P = 0·023) and only allow their infant to eat at set times (P < 0·001). Adjusting for potential confounders, racial/ethnic minority mothers had higher scores for factors 1 (concern about infant undereating or becoming underweight), 2 (concern about infant's hunger), 4 (concern about infant overeating or becoming overweight) and 5 (feeding infant on a schedule), and lower scores for factor 7 (social interaction with the infant during feeding) than White mothers. Racial/ethnic differences were not found for the other two factors.

CONCLUSIONS

Differences in maternal feeding practices and beliefs across race/ethnicity are present at 6 months postpartum.

Does social modeling increase infants' willingness to accept unfamiliar foods?

Despite a rich knowledge base about infants' social learning and studies observing social referencing in other species in food contexts, we know surprisingly little about social learning about food among human infants. This gap in the literature is particularly surprising considering that feeding unfamiliar foods to infants is a very common experience as infants begin to eat solid foods. The present study examines whether parental social modeling influences infants' willingness to accept unfamiliar foods. In two Zoom sessions, parents will be asked to feed unfamiliar foods to their 6- to 24-month-old infants (different unfamiliar foods in each session). In both sessions, infants' food acceptance and rejection will be measured. In the first session, parents will be asked to do what they would typically do; spontaneous social modeling will be recorded. In the second session, parents will be instructed to model eating the unfamiliar food. We will examine associations between infants' willingness to eat unfamiliar foods, parent social modeling, and extant parent and infant characteristics.

Cross-cultural adaptation and validation of the Infant Feeding Style Questionnaire in Brazil

We cross-culturally adapted and validated the Infant Feeding Style Questionnaire (IFSQ) in Brazil. The cross-cultural adaptation and content validity assessment was conducted in five steps: translation, synthesis of translations, back-translation, evaluation by experts, and pre-test. To evaluate reliability, construct validity, and floor and ceiling effects, interviews were conducted with 465 mother-infant pairs at Primary Health Centers in the Federal District, Brazil. The mothers answered the Brazilian Portuguese version of the IFSQ (IFSQ-Br), which evaluated four feeding styles (laissez-faire, pressuring, restrictive, and responsive) from 9 sub-constructs. The indulgent style was not evaluated due to time limitation. We performed reliability analysis using Cronbach’s alpha coefficient and construct validity was evaluated through Confirmatory Factor Analysis. Higher means were found in the sub-constructs of the responsive and restrictive styles. The IFSQ-Br presented adequate reliability (α = 0.73) with values for the Cronbach’s alpha coefficient of the sub-constructs ranging from 0.42 to 0.75. In the Confirmatory Factor Analysis, the final models presented good fit, with the Comparative Fit Indices (CFI) ranging from 0.86 to 1.0 and the Root-Mean Squared Error of Approximation (RMSEA) between 0.0 and 0.09. The IFSQ-Br was shown to be a valid and reliable questionnaire to evaluate maternal feeding beliefs and behaviors in Brazil. Future studies should evaluate the psychometric properties of the indulgent style and include mother-infant pairs from different cultural contexts in Brazil.

Infant feeding in diverse families; the impact of ethnicity and migration on feeding practices

OBJECTIVE

To investigate differences in infant feeding practices and styles by maternal migration status.

DESIGN

Prospective cohort study.

SETTING

Maternity unit of a large hospital in Northern England PARTICIPANTS: Women recruited to the Born in Bradford longitudinal cohort study MEASUREMENTS: Breastfeeding initiation; breastfeeding at six months; breastfeeding at twelve months; timing of introduction of complementary feeding; maternal feeding style at twelve months.

FINDINGS

Migrant women were more likely to initiate breastfeeding and continue breastfeeding for longer compared to native women. Native women also introduced complementary feeding earlier than migrant women. There was evidence of feeding practices among second= generation migrants becoming increasingly more aligned with those of native women, with lower breastfeeding rates and earlier introduction of complementary feeding compared to first-generation migrants. Migrant women were more likely to adopt a 'Demanding' feeding style, with the strongest associations seen in first-generation migrants.

KEY CONCLUSIONS

Migration status is an important factor to consider in reference to infant feeding practices. This is particularly important in considering intergenerational changes in families with migration backgrounds and the potential of culture to impact on family practices.

IMPLICATIONS FOR PRACTICE

Interventions to maintain cultural norms around infant feeding in families with migration backgrounds would be beneficial, due to the observed higher rates of breastfeeding in first-generation migrants. Targeted interventions to improve breastfeeding in white British native women should consider the role that culture can play in encouraging positive health behaviours.

Promoting Responsive Bottle-Feeding Within WIC: Evaluation of a Policy, Systems, and Environmental Change Approach

BACKGROUND

Bottle-fed infants are at greater risk for overfeeding and rapid weight gain (RWG); evidence-based strategies for promoting healthy bottle-feeding practices are needed.

OBJECTIVE

Our aim was to assess whether policy, systems, and environmental (PSE) strategies for promoting responsive bottle-feeding practices within the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) were associated with lower risk for RWG.

DESIGN

We conducted a matched-pair cluster randomized trial. PSE strategies were implemented at 3 WIC clinics in Los Angeles County. PSE clinics were compared with 3 matched control clinics. Mothers and infants were assessed when infants were newborn and 3 months and 6 months of age.

PARTICIPANTS/SETTING

Participants were mothers (n = 246) who enrolled their newborn infants (younger than 60 days) into WIC between May and August 2019.

MAIN OUTCOME MEASURES

Infant weight was assessed and standardized to sex- and age-specific z scores. RWG was defined as weight-for-age z score change > 0.67. Mothers completed questionnaires assessing responsive and pressuring feeding styles, breast- and bottle-feeding patterns, and perceptions of WIC experiences.

STATISTICAL ANALYSES PERFORMED

Logistic regression with estimation via generalized estimating equations and linear mixed models with repeated measures assessed effects of PSE strategies on categorical and continuous outcomes, respectively.

RESULTS

Infants in PSE clinics had significantly lower likelihood of exhibiting RWG (P = .014) than infants in control clinics. Mothers in PSE and control clinics reported similar levels of responsive and pressuring feeding style and similar prevalence of breastfeeding and bottle-feeding. Mothers in PSE clinics trended toward feeling better supported with respect to their decision to bottle-feed (P = .098) and had more stable intentions to stay in the WIC program (P = .002) compared with mothers in control clinics.

CONCLUSIONS

PSE strategies focused on promoting more inclusive assessment of infant feeding, tailored bottle-feeding counseling, and increased education and support for responsive bottle-feeding were associated with lower risk for RWG among WIC infants.

Learning to overeat in infancy: Concurrent and prospective relationships between maternal BMI, feeding practices and child eating response among Hispanic mothers and children

BACKGROUND

Parents play a key role in shaping children's eating behaviours and self-regulation. There is limited data on how maternal weight influences feeding practices in the first year of life.

OBJECTIVE

To examine the relationships between maternal BMI, feeding practices and infant eating behaviours related to self-regulation.

METHODS

Participants were 160 mother-infant dyads. A longitudinal design was used to examine concurrent and prospective associations between maternal 6-month postpartum BMI, mothers' feeding practices at 6 months (Infant Feeding Practices Questionnaire) and children's eating behaviours at 6 months (Baby Eating Behaviour Questionnaire) and 12 months (Child Eating Behaviour Questionnaire).

RESULTS

Higher maternal BMI was associated positively with mothers' use of restrictive feeding practices (β = 0.036, p = 0.033), and inversely with responsivity to infant satiety cues (Spearman partial r = -0.249, p = 0.002) at 6 months. Mother's restrictive feeding practices were associated with infant food responsiveness (β = 0.157, p = 0.009) and emotional overeating (β = 0.118, p = 0.005) at 12 months. Maternal use of responsive feeding practices was associated with lower infant food responsiveness at 6 months (Spearman partial r = -0.173, p = 0.031) and lower emotional overeating at 12 months (Spearman partial r = -0.183, p = 0.022).

CONCLUSIONS

Our findings add to studies suggesting that feeding practices can provide mechanistic pathways in the intergenerational transmission of obesity. Postpartum family-system approaches focusing on maternal health while integrating infant feeding guidance may confer benefits in improving maternal-child health.

Feeding style profiles are associated with maternal and infant characteristics and infant feeding practices and weight outcomes in African American mothers and infants

Much literature links individual feeding styles to infant feeding practices and growth; however, parents' feeding styles are not discrete and may vary by context. We use latent profile analysis (LPA) as a person-centered approach to categorize infant feeding style patterns, test factors predicting profile membership, and examine if profiles are associated with infant feeding and weight. Additionally, we test the impact of a responsive feeding intervention on profile membership and stability. Data come from 270 African-American women and infants participating in the Mothers and Others Study, an early life obesity prevention intervention. LPA was used to categorize mothers across five constructs (laissez-faire, pressuring, restrictive, responsive and indulgent) measured at 28-weeks gestation and 3- and 15-months postpartum. Adjusted multinomial regression and regression models test the characteristics associated with profile membership and the associations between profile membership and breastfeeding and infant weight-for-age z-score (WAZ). We identified two groups (Positive and Less Responsive) prenatally, an additional group (High Controlling) at 3 months and a fourth group (High Indulgent) at 15 months. Several characteristics differed between the groups, including maternal age, income and depressive symptoms, infant sex and temperament, and treatment group. Mothers in the Positive group were more likely to breastfeed at 3 months. Infants with mothers in the High Controlling group had higher WAZ at 15 months. The intervention was associated with more Positive feeding practices at 15 months and a greater likelihood of remaining in the Positive group across the study. LPA identified profiles that are associated with maternal and infant characteristics and treatment group and with better feeding practices and growth outcomes, providing preliminary evidence that early intervention promoting more responsive feeding profiles may improve infant outcomes.

Complementary Feeding Practices and Parental Pressure to Eat among Spanish Infants and Toddlers: A Cross-Sectional Study

The introduction of complementary foods is a crucial stage in the development and determination of infants’ health status in both the short and longer-term. This study describes complementary feeding practices among infants and toddlers in Spain. Also, relationships among sample characteristics (both parents and their child), feeding practices (timing, type of complementary food), and parental pressure to eat were explored. Cognitive interviewing with 18 parents was used to refine the survey questions. Responses from a national random sample of 630 parents, who were responsible for feeding their infants and toddlers aged 3–18 months, were obtained. Solids, often cereals and/or fruits first, were introduced at a median age of five months. Fish and eggs were introduced around the age of nine and ten months. Almost all children were fed with home-prepared foods at least once per week (93%), and in 36% of the cases, salt was added. Interestingly, higher levels of parental pressure to eat were found in female infants, younger parents, parents with a full-time job, the southern regions of Spain, and in infants who were not fed with home-prepared foods. Our insights underline the importance of clear feeding recommendations that can support health care professionals in promoting effective strategies to improve parental feeding practices.

Maternal feeding style and child weight status among Hispanic families with low-income levels: a longitudinal study of the direction of effects

BACKGROUND

The home environment is a central and modifiable influence on the development of childhood obesity. Evidence supports the central role of parents in shaping problematic child eating behaviors and excess weight. Most studies of feeding emphasize parent-driven influences without taking into account the child's role in eating interactions. Few studies have addressed the bi-directional nature of feeding dynamics in studies of young children.

METHODS

The goals of this study were: 1) to examine if parental feeding styles during preschool (4-5 years) predict child weight status at 7-9 years, and 2) to examine the direction of effects between parental feeding styles and child weight status over time. Participants were part of a larger longitudinal study of Hispanic Head Start families living in the West South Central United States. Data from mother/child dyads were collected at three time points: Time 1 (ages 4-5), Time 2 (ages 5 ½-6 ½), and at Time 3 (ages 7-9). Only data from the Times 1 and 3 were used in the current analyses. A total of 128 mothers and their children had data on all variables needed for the analyses. Assessments included parent-reported feeding styles, feeding practices, acculturation, child eating behaviors, and child height and weight. Hierarchical regression was used to examine the first aim; a cross-lagged panel analysis examined the second aim.

RESULTS

An indulgent parental feeding style at ages 4-5 was associated with increased child BMI z-score at ages 7-9. Indulgent feeding significantly contributed to child BMI z-score beyond demographics, baseline child BMI z-score, parental acculturation, and child eating behaviors. Regarding the direction of effects in parental feeding interactions, the cross-lagged analyses showed that both indulgent feeding style and authoritative feeding style at Time 1 positively predicted child BMI z-scores at Time 3. Child effects were significant as well. Child BMI z-score at Time 1 positively predicted indulgent feeding and negatively predicted authoritarian feeding at Time 3.

CONCLUSIONS

Indulgent feeding should be addressed in future family-focused childhood obesity initiatives focused on young children and their parents.

Parental Feeding Styles and Their Association With Complementary Feeding Practices and Growth in Mexican Children

Background: Complementary feeding practices and corresponding parental feeding styles influence nutritional status in later stages of childhood. Findings on the association of these variables with infant growth remain inconsistent; in Mexico, a research gap exists in this area. Research Aims: (1) To characterize parental feeding styles and complementary feeding practices, and (2) to evaluate the association of parental feeding styles with complementary feeding practices and infant growth at 6 and 9 months of age. Methods: Data were collected from a prospective Mexican birth cohort. Parental feeding styles, complementary feeding practices, and anthropometric data from 263 to 234 mother-child pairs (infants of 6 and 9 months of age, respectively) were analyzed. Logistic and linear regression models were used to determine the associations between variables. Results: The predominant parental feeding style was the "responsive style" (90%). Only 43.7 and 8.1% of 6- and 9-month-old infants, had adequate complementary feeding practices, respectively. At 6 months, mothers who were responsive to satiety signals had 11% lesser possibilities (OR = 0.89, 95% CI [0.80, 0.98]) of their infant having inadequate complementary feeding practices than their counterparts and "pressuring to finish" and "pressuring to eat cereal" sub-constructs were associated with lower weight for length and body mass index Z-scores (p = 0.02). Conclusions: A high proportion of infants (>40%) did not meet international recommendations. The "pressuring" parental feeding style sub-constructs were associated with growth indicators in 6-month old infants. This emphasizes the importance of promoting parental responsiveness to infant appetite and satiety signals to achieving adequate complementary feeding practices.

Toddler obesity prevention: A two-generation randomized attention-controlled trial

Rapid weight gain increases risks of obesity and associated co-morbidities. The objective was to reduce the rate of body mass index (BMI) growth (BMI z score), relative to control. Secondary outcomes were toddler-mother physical activity, mealtime interactions and fruit/vegetable intake. The randomized three-arm, eight-session, 4-month trial, conducted 2009-2013, included two intervention arms (responsive parenting and maternal lifestyle) and an attention control (home safety). Baseline and 6- and 12-month follow-up evaluations included weight and length/height, ankle accelerometry, video-recorded mealtime interactions (Emotional Availability Scales) and 24-h diet recalls (Healthy Eating Index-2015 [HEI-2015]). Analyses used linear mixed-effects models with repeated measures comparing intervention versus control changes in BMI z score. We recruited 277 racially mixed (70% African American) toddler-mother dyads (mean ages 20.1 months and 27.3 years) from US WIC and primary care clinics and randomized them into intervention versus control; 31% toddlers and 73% mothers were overweight/obese. At follow-up, changes in the rate of toddler BMI z score and maternal BMI were non-significant. Maternal lifestyle group toddlers and mothers spent 24.43 and 11.01 more minutes in physical activity (95% confidence interval [CI]: 2.55, 46.32, and 95% CI: 1.48, 20.54, respectively). Fruit intake increased in both intervention groups. Hostile mealtime interactions increased in the maternal lifestyle group, and in supplementary analyses, mealtime interactions were significantly higher in the responsive parenting group than in the maternal lifestyles group, suggesting that toddler dietary interventions include responsive parenting. Intervention effects were stronger among older versus younger toddlers. Despite no impact on weight gain, additional research should examine integrated two-generation responsive parenting and maternal lifestyle interventions among toddler-mother dyads.

Evaluating the pathways linking complementary feeding practices to obesity in early life

The complementary feeding period, when solids and liquids other than breast milk and formula are added to the infant diet, is an important development window shaping infant growth and weight gain, metabolic development, and lifelong eating practices. Yet, relatively little is known about how the timing and types of foods offered to infants at this stage may shape their growth and subsequent risk of developing obesity. This narrative review describes the existing literature on complementary feeding practices, discusses potential biological and behavioral pathways linking complementary feeding practices to the development of obesity, and offers potential avenues for intervention. While further research is needed to more fully understand optimal complementary feeding practices, existing evidence supports the importance of healthful early feeding practices in the physiological and behavioral regulation of growth and metabolism and the need for early intervention to prevent the development of obesity.

Impact of early rapid weight gain on odds for overweight at one year differs between breastfed and formula-fed infants

BACKGROUND

Early rapid weight gain (RWG) increases, whereas longer durations of breastfeeding decreases, odds for later obesity.

OBJECTIVES

To determine the independent and interactive effects of early weight gain and diet on infant weight status trajectories and odds for overweight at 1 year.

METHODS

We conducted secondary analysis on data from two longitudinal trials with repeated anthropometric measures. One trial consisted of predominantly or exclusively breastfed (BF, n = 97) infants, whereas the other consisted of exclusively formula-fed (FF, n = 113) infants. Weight-for-length z-score (WLZ) change from 0.5 to 4.5 months was used to categorize early weight gain as slow (<-0.67; SWG), normal (-0.67 to 0.67; NWG) or rapid (>0.67; RWG). Linear-mixed effects models were fit to examine the independent effects and interaction of early diet (BF, FF) and weight gain (SWG, NWG, RWG) groups on WLZ trajectories; logistic regression was used to assess odds for overweight at 1 year.

RESULTS

While similar percentages (41%) of BF and FF infants experienced RWG, we found a significant diet × early weight gain group interaction (P < .001) on weight status. At 1 year, the WLZ of FF infants with RWG (1.57 ± 0.99) was twice that of BF infants with RWG (0.83 ± 0.92). Using BF infants with NWG as the reference group, FF infants with RWG had increased odds [OR: 25.3 (95% CI: 3.21, 199.7)] for overweight at 1 year, whereas BF infants with RWG did not.

CONCLUSIONS

Early diet interacts with early weight gain and influences weight status trajectories and overweight risk at 1 year.

Associations between maternal and paternal feeding styles of infants in a racially diverse US birth cohort

BACKGROUND

Maternal feeding style has been associated with childhood obesity and has been the target of numerous interventions, but few studies included fathers.

OBJECTIVES

We assessed correlations and associations between maternal and paternal feeding style.

METHODS

We examined 202 mothers, fathers, and infants in Nurture, a racially diverse US cohort (2013-2017). Mothers and fathers completed the Infant Feeding Style Questionnaire when infants were 6 and 12 months. We examined unadjusted correlations using Spearman's Rho and adjusted associations using linear regressions.

RESULTS

All feeding styles were significantly correlated. After adjustment, maternal feeding style was associated with paternal feeding style at 6 and 12 months for responsive (ß 0.31; CI 0.18, 0.45; P ≤ 0.0001 and ß 0.67; CI 0.50, 0.84; P ≤ 0.0001), restrictive (ß 0.24; CI 0.09, 0.38; P = 0.001 and ß 0.44; CI 0.29, 0.59; P ≤ 0.0001), pressuring (ß 0.46; CI 0.34, 0.58; P ≤ 0.0001 and ß 0.51; CI 0.38, 065; P ≤ 0.0001), indulgent (ß 0.36; CI 0.20, 0.52; P ≤ 0.0001 and ß 0.57; CI 0.40, 0.73; P ≤ 0.0001), and laissez-faire (ß 0.39; CI 0.24, 0.55; P ≤ 0.0001 and ß 0.55; CI 0.37, 0.72; P ≤ 0.0001).

CONCLUSIONS

Maternal and paternal feeding styles were correlated. Associations held after adjustment, suggesting that mothers and fathers are in relative agreement in their reporting.

Phenotypes of controlling feeding behaviours in mothers of toddlers: A mixed methods study

BACKGROUND

Maternal feeding behaviours, in particular controlling behaviours, are associated with risk of childhood obesity.

OBJECTIVES

To qualitatively examine patterns of mothers' beliefs and behaviours around controlling feeding through a semi-structured interview and to examine associations of those patterns with participant demographic characteristics and classical child feeding instruments.

METHODS

A convenience sample of mothers (N = 35) of toddlers (mean age 25 months) participated in a semi-structured interview about their child feeding beliefs and behaviours. Anthropometrics were measured. Transcripts were analyzed using narrative analysis for patterns from which two emerged, known as phenotypes. A coding scheme was created and reliably applied. Bivariate correlates of the phenotypes with participant child characteristics and mother self-reported feeding behaviours were examined.

RESULTS

The phenotypes were High Covert Control (n = 12) and Shared Control (n = 23). High Covert Control phenotype membership was correlated with higher child and mother BMI (body mass index) and child female sex. Shared Control phenotype membership was correlated with lower child and mother BMI and greater pressure to eat.

CONCLUSIONS

Two controlling feeding phenotypes emerged among mothers of toddlers, which were associated with participant characteristics including BMI, but did not map onto classical child feeding instruments.

Responsive Feeding, Infant Growth, and Postpartum Depressive Symptoms During 3 Months Postpartum

Responsive feeding is crucial to the formation of life-long healthy eating behavior. Few studies have examined maternal responsive feeding in early infancy among a Chinese population. This prospective study describes maternal responsive feeding and factors associated with maternal responsive feeding, with emphasis on infant growth and maternal depressive symptoms, during the first 3 months postpartum in Taiwan. From 2015 to 2017, 438 pregnant women were recruited and followed at 1 and 3 months postpartum. Maternal responsive feeding at 3 months was measured on a 10-item 5-point Likert-type scale. Maternal depressive symptoms were measured using the Edinburgh Postnatal Depression Scale with a cutoff score of 10. Infant growth was categorized into four groups based on weight-for-length Z scores from birth to 3 months: no change, increase but in the normal range, increase to overweight, and decrease to underweight. Multiple regression revealed that postpartum depressive symptoms, primipara, and decreased infant weight-for-length Z score were negatively associated with maternal responsive feeding, while exclusive breastfeeding and maternal age younger than 29 years were positively associated with maternal responsive feeding. Heath professionals should educate mothers on responsive feeding, with emphases on first-time and non-exclusive breastfeeding mothers, as well as those with depressive symptoms, advanced maternal age, and infants who are becoming underweight.

Barriers and enablers to Caregivers Responsive feeding Behaviour (CRiB): A mixed method systematic review protocol

Background: Childhood overweight and obesity is a major public health issue. Responsive feeding has been identified as having a protective effect against child overweight and obesity, and is associated with healthy weight gain during infancy. Responsive feeding occurs when the caregiver recognises and responds in a timely and developmentally appropriate manner to infant hunger and satiety cues. Despite its benefits, responsive feeding is not ubiquitous. To better support caregivers to engage in responsive feeding behaviours, it is necessary to first systematically identify the barriers and enablers associated with this behaviour. This mixed-methods systematic review therefore aims to synthesise evidence on barriers and enablers to responsive feeding using the COM-B model of behavioural change. Methods: 7 electronic databases will be searched (Maternal and Infant Care, CINAHL, Cochrane, PubMed, Medline, PsycINFO, EMBASE). Studies examining factors associated with parental responsive and non-responsive feeding of infants and children (<2 years) will be included. Papers collecting primary data, or analysing primary data through secondary analysis will be included. All titles, abstracts and full texts will be screened by two reviewers. Quantitative and qualitative data from all eligible papers will be independently extracted by at least two reviewers using pre-determined standardised data extraction forms. Two reviewers will independently assess the methodological quality of the studies using the Mixed Methods Appraisal Tool (MMAT). This review will be reported according to the Preferred Reporting Items for Systematic reviews and Meta Analyses (PRISMA). Ethics and dissemination: Ethical approval is not required for this review as no primary data will be collected, and no identifying personal information will be present. The review will be disseminated in a peer reviewed journal. PROSPERO registration: CRD42019144570 (06/08/2019).

Barriers and enablers to Caregivers Responsive feeding Behaviour (CRiB): A mixed method systematic review protocol

Background: Childhood overweight and obesity is a major public health issue. Responsive feeding has been identified as having a protective effect against child overweight and obesity, and is associated with healthy weight gain during infancy. Responsive feeding occurs when the caregiver recognises and responds in a timely and developmentally appropriate manner to infant hunger and satiety cues. Despite its benefits, responsive feeding is not ubiquitous. To better support caregivers to engage in responsive feeding behaviours, it is necessary to first systematically identify the barriers and enablers associated with this behaviour. This mixed-methods systematic review therefore aims to synthesise evidence on barriers and enablers to responsive feeding using the COM-B model of behavioural change. Methods: 7 electronic databases will be searched (Maternal and Infant Care, CINAHL, Cochrane, PubMed, Medline, PsycINFO, EMBASE). Studies examining factors associated with parental responsive and non-responsive feeding of infants and children (<2 years) will be included. Papers collecting primary data, or analysing primary data through secondary analysis will be included. All titles, abstracts and full texts will be screened by two reviewers. Quantitative and qualitative data from all eligible papers will be independently extracted by at least two reviewers using pre-determined standardised data extraction forms. Two reviewers will independently assess the methodological quality of the studies using the Mixed Methods Appraisal Tool (MMAT). This review will be reported according to the Preferred Reporting Items for Systematic reviews and Meta Analyses (PRISMA). Ethics and dissemination: Ethical approval is not required for this review as no primary data will be collected, and no identifying personal information will be present. The review will be disseminated in a peer reviewed journal. PROSPERO registration: CRD42019144570 (06/08/2019).

Validation of the Infant Feeding Beliefs Questionnaire (IFBQ) among pregnant African- American women and their study partners

Maternal feeding beliefs and practices have been associated with weight gain in infants and young children. Less work examines feeding beliefs prenatally or the feeding beliefs of other non-maternal caregivers (NMCs) who play important roles in infant feeding. This study validates a scale, the Infant Feeding Beliefs Questionnaire (IFBQ), to assess feeding beliefs during pregnancy among African-American women and other caregivers and tests whether the resulting belief constructs (laissez-faire, restrictive, responsive, pressuring and indulgent) are associated with maternal and NMC characteristics. Data come from 429 pregnant women and 374 NMCs including fathers, grandmothers and other family and friends enrolled in the baseline 28-week gestation visit of the Mothers and Others Study, a family-based, randomized control trial to support healthy infant feeding and prevent obesity. Confirmatory factor analysis (CFA) was used to test the fit of four a priori feeding constructs. Models were modified iteratively in mothers and then separately tested in the NMCs sample. Construct scores were created by averaging the remaining items and scale reliability was assessed. External validity was tested using bivariate and multivariable regression models. We validated five feeding belief constructs, measured through 8 sub-constructs. Reliability coefficients ranged from 0.58 for laissez faire to 0.76 for pressuring. Goodness of fit indices for CFA models indicated good fit with CFIs from 0.97 to 0.99 and RMSEA from 0.00 to 0.06. Construct scores differed significantly by depressive symptoms, obesity, education, income, and previous children in mothers and NMCs. The IFBQ may be used among mothers and NMCs to assess feeding beliefs beginning in the prenatal period, providing a tool to assess the longitudinal development of feeding beliefs and to highlight avenues for intervention on feeding practices during a critical period for behavior change.

Self-efficacy, infant feeding practices, and infant weight gain: An integrative review

It has been suggested that self-efficacy specific to parenting or feeding may influence the decisions parents make regarding infant feeding; however, a review of this topic has not been conducted. The purpose of this integrative review is to synthesize the literature regarding the potential role of self-efficacy in infant feeding practices or infant weight gain. A total of 40 articles were used to guide this review, which were classified into three categories examining an association with self-efficacy (1) breastfeeding; (2) infant feeding practices such as parental feeding style and dietary quality; and (3) infant weight gain. Evidence regarding breastfeeding self-efficacy (BFSE) and breastfeeding is extensive; mothers with a higher sense of BFSE more often initiate breastfeeding and breastfeed for longer durations. The evidence regarding self-efficacy and the association with infant feeding practices other than breastfeeding is sparse. However, several studies report that mothers who have a higher sense of self-efficacy are more likely to follow infant feeding practices which align with recommendations. The authors have speculated an association between self-efficacy and infant weight gain; yet, to date, no study has found a significant association. More research is needed on the topic, particularly in diverse populations and with fathers and mothers.

Caregiver feeding practices and child weight outcomes: a systematic review

BACKGROUND

As part of the USDA-Department of Health and Human Services Pregnancy and Birth to 24 Months Project, we conducted systematic reviews (SRs) on topics important for health and nutrition of young children.

OBJECTIVES

The purpose of the present SR was to examine the relation between caregiver feeding practices in children from birth to 24 mo and child weight gain, size, and body composition.

METHODS

A search of articles published from January 1980 to January 2017 in 4 databases identified 8739 references. Nutrition Evidence Systematic Review (NESR) analysts used the Nutrition Evidence Library Risk of Bias Assessment Tool to assess potential bias in the studies, and a Technical Expert Collaborative graded the body of evidence using the NESR grading rubric.

RESULTS

Twenty-seven articles were included in this review (8 controlled trials, 19 longitudinal cohort studies). Moderate evidence from randomized controlled trials suggests that providing responsive feeding guidance to teach mothers to recognize and respond appropriately to children's hunger and satiety cues can lead to "normal" weight gain and/or "normal" weight status in children aged ≤2 y compared with children whose mothers did not receive responsive feeding guidance. Moderate evidence from longitudinal cohort studies indicates an association between maternal feeding practices and the child's weight status and/or weight gain, but the direction of effect has not been adequately studied. Restrictive feeding practices are associated with increased weight gain and higher weight status, and pressuring feeding practices are associated with decreased weight gain and lower weight status. Evidence suggests that a mother's feeding practices are related to concerns about her child's body weight.

CONCLUSIONS

This review highlights the importance of the interaction between caregivers and infants and toddlers related to child feeding practices on children's weight outcomes. Research is needed on more diverse populations with consistent methodological app-roaches and objective measures.

Parental intuitive eating behaviors and their association with infant feeding styles among low-income families

INTRODUCTION

Feeding styles, the attitudes and behaviors parents use to direct their child's eating, shape a child's ability to self-regulate food intake and affects their future risk of obesity. This study examined how parental intuitive eating, where parents follow their own hunger and satiety cues, relates to infant feeding styles in a low-income, predominately Black population.

METHODS

Parents of healthy infants aged 5.5-12.5 months were recruited during well-child visits at two urban primary care clinics. Parent's intuitive eating behaviors and infant feeding styles were measured using the Intuitive Eating Scale-2 (IES-2) and the Infant Feeding Style Questionnaire (IFSQ), respectively. Multivariable regression analysis, controlling for maternal and child demographic variables, was conducted to determine the relationship between parent intuitive eating behaviors and five infant feeding styles: restrictive, pressuring, indulgent, laissez-faire, and responsive.

RESULTS

201 parents completed the study, 90% were mothers and 69% were Black. Average infant age was 8.8 ± 2.0 months. Parents who reported relying on their own hunger and satiety cues when eating were more likely to feed their infant in a responsive style (β 0.10 ± 0.04, p < 0.05). Parents who reported eating unconditionally, not labeling foods as forbidden, were more likely to feed their infant in a laissez-faire (β 0.16 ± 0.06, p < 0.05) and indulgent (β 0.09 ± 0.03, p < 0.05) feeding style.

CONCLUSIONS

Parental intuitive eating behaviors are associated with both responsive and non-responsive infant feeding styles. Future studies should examine how parental intuitive eating and infant feeding styles affect infant growth trajectories.

Additive effects of household food insecurity during pregnancy and infancy on maternal infant feeding styles and practices

Food insecurity, or the limited access to food, has been associated with maternal child feeding styles and practices. While studies in other parenting domains suggest differential and additive impacts of poverty-associated stressors during pregnancy and infancy, few studies have assessed relations between food insecurity during these sensitive times and maternal infant feeding styles and practices. This study sought to analyze these relations in low-income Hispanic mother-infant pairs enrolled in a randomized controlled trial of an early obesity prevention program (Starting Early). Food insecurity was measured prenatally and during infancy at 10 months. Food insecurity timing was categorized as never, prenatal only, infancy only, or both. Regression analyses were used to determine relations between food insecurity timing and styles and practices at 10 months, using never experiencing food insecurity as the reference, adjusting for family characteristics and material hardships. 412 mother-infant pairs completed 10-month assessments. Prolonged food insecurity during both periods was associated with greater pressuring, indulgent and laissez-faire styles compared to never experiencing food insecurity. Prenatal food insecurity was associated with less vegetable and more juice intake. If food insecurity is identified during pregnancy, interventions to prevent food insecurity from persisting into infancy may mitigate the development of obesity-promoting feeding styles and practices.

Contributions of nonmaternal caregivers to infant feeding in a low-income African-American sample

Infant feeding is a well-established topic of interest in obesity research, yet few studies have focused on contributions of nonmaternal caregivers (NMCs)-such as fathers, grandparents, and daycare providers-to infant feeding. Data from the Infant Care, Feeding and Risk of Obesity Project in North Carolina were used to investigate (a) which factors were associated with NMC feeding styles and (b) how NMCs' and mothers' feeding styles compared. Multivariate regression models utilizing random effects were used to analyse data from 108 NMCs who were identified by mothers as being heavily involved in infant feeding. Feeding styles were measured using the Infant Feeding Style Questionnaire. Several individual characteristics were important. Higher laissez faire-attention scores were reported by men and NMCs who lived in the same household as infant. Men reported higher indulgent-coax and indulgent-pamper scores. Perceptions of fussier infants, older infant age, and higher infant weight-for-length z-scores were also important. Mothers' and NMCs' feeding styles differed. Compared with mothers, grandparents reported lower laissez faire and indulgent-permissive scores. Fathers reported higher pressure-soothe and indulgent scores. Daycare providers reported higher restriction-diet quality and responsive satiety. Feeding styles were also predicted to change over time for all caregiver types. These findings highlight the importance of helping all caregivers develop skills that will promote optimal infant feeding outcomes. Given the paucity of research in this area, it is important to improve our understanding of what influences caregivers' feeding styles, especially among diverse populations, and how exposure to different feeding styles may shape children's obesity risk.

Picky eating, pressuring feeding, and growth in toddlers

Several common theoretical frameworks have posited causal pathways between picky eating, pressuring feeding, and growth in early childhood. The evidence to support these pathways is limited. This observational cohort study sought to examine the cross-lagged associations between mother-reported pressuring feeding, mother-reported child picky eating, and measured weight-for-length z-score (WLZ) across child ages 21, 27, and 33 months (n = 244). Cross-lagged analysis was used to evaluate longitudinal associations between these three constructs. The sample was 50.5% white, 52.3% male and 37.8% of mothers had a high school education or less. Mean WLZ was 0.52, 0.41, and 0.38 at each age, respectively. Pressuring feeding, picky eating, and WLZ each tracked strongly from 21 to 33 months. There were concurrent associations between pressuring feeding and picky eating. However, there were no prospective associations between pressuring feeding and future WLZ; WLZ and future pressuring feeding; pressuring feeding and future picky eating; picky eating and future pressuring feeding; or picky eating and future WLZ. Our results do not support causal relationships between picky eating, pressuring feeding, and growth in toddlerhood. Future work that examines alternative mechanisms shaping growth in early childhood is needed.

Development of Feeding Cues During Infancy and Toddlerhood

PURPOSE

To enhance responsive feeding, this study aimed to characterize the development of feeding cues during infancy and toddlerhood.

STUDY DESIGN AND METHODS

A secondary analysis was performed on a dataset of first-time, low-income African American mother-infant pairs assessed at infant age 3, 6, 9, 12, and 18 months. A subsample with the 15 highest, middle, and lowest infant body mass index (BMI) Z-scores at 18 months was selected (n = 45). Using video-recorded home feedings, early, active, and late receptiveness and fullness cues were assessed using the Responsiveness to Child Feeding Cues Scale at each time point. Descriptive statistics were used to characterize development.

RESULTS

Early receptiveness cues were relatively rare over time, whereas active receptiveness cues were much more common. However, there were changes over time. For example, settling into the feeding decreased from ~50% at 3 and 6 months to 4.8% by 18 months, whereas postural attention and reaching for food increased after 6 months. In the first 6 months, falling asleep and decreasing muscle tone and activity level were the most common early fullness cues. Thereafter, taking interest in surroundings was most prevalent. Active fullness cues became increasingly diverse after 6 months, led by more assertive cues such as pushing or pulling away and communicating "no" verbally or nonverbally.

CLINICAL IMPLICATIONS

These findings provide an empirical description of waxing and waning in feeding cues and indicate increasing intentionality of cues over the first 18 months of life. Knowing common cues across development may aid clinicians in enhancing parental feeding responsiveness, avoiding overfeeding, thereby decreasing risk of early childhood obesity.

Consumption of obesogenic foods in non-Hispanic black mother-infant dyads

Obesity continues to be a problem in the United States. Of particular concern is the epidemic of early childhood obesity. A significant predictor of child diet is maternal diet, but little is known about this relationship during infancy. This study examined the association between maternal and infant consumption of key food groups from 6 to 18 months using data from the Infant Care, Feeding, and Risk of Obesity Study, a prospective cohort of 217 non-Hispanic black, low-income, first-time mothers. Using data from 24-hr dietary recalls collected during in-home visits at 6, 9, 12, and 18 months, we assessed longitudinal associations between mother and child intake of both energy-dense, nutrient-poor (obesogenic) food groups and fibre-, nutrient-rich food groups using random intercept logistic regression. Both mothers and their infants had high intake of sugar-sweetened beverages, desserts, and sweets and low intake of vegetables and whole grains. Infant consumption of key food groups was strongly associated with maternal consumption, suggesting the need for focused interventions to target maternal diet as a pathway to decreasing risk for the establishment of poor dietary patterns early in life.

Pacifier Use and Early Life Weight Outcomes in the Intervention Nurses Start Infants Growing on Healthy Trajectories Study

BACKGROUND

Although widely used by infants, little is known about the long-term effects of pacifiers. We investigated relationships between pacifier use in infancy and appetite, temperament, feeding, and weight outcomes through age 2 years using data from the Intervention Nurses Start Infants Growing on Healthy Trajectories study.

METHODS

Mother-newborn dyads were randomized to a responsive parenting intervention for obesity prevention or a control group. Infants with data on pacifier use (n = 250) were categorized as using a pacifier beyond early infancy (≥4 months of age) or not. Anthropometrics were measured at 6 months, 1, and 2 years with overweight defined as weight-for-length ≥95th percentile at 1 year and BMI ≥85th percentile at 2 years. Mothers completed questionnaires on temperament, appetite, and feeding.

RESULTS

Infants who used a pacifier at 4 months or later (68%) had greater conditional weight gain from birth to 6 months (p = 0.01), weight-for-length z-score at 1 year (p < 0.001), and BMI z-score at 2 years (p < 0.001) than infants who did not. Infants using a pacifier at ≥4 months were more likely to be overweight at ages 1 year (11.7% vs. 1.3%, p = 0.03) and 2 years (20.1% vs. 7.9%, p = 0.03). Pacifier use was associated with shorter breastfeeding duration and less responsive parent feeding styles, but these variables did not mediate the relationship between pacifiers and weight. Parent-reported temperament and appetite were unrelated to pacifier use.

CONCLUSIONS

Pacifier use beyond early infancy is associated with accelerated infant growth and toddler overweight, although the reasons for this relationship are unclear.

Socioeconomic Position and Picky Eating Behavior Predict Disparate Weight Trajectories in Infancy

Infant weight gain has long-term implications for the establishment of overall health. We examined whether socioeconomic position (SEP), the use of pressure as a feeding practice, and picky eating relate to changes infant in weight-for-length (WFL). A modified developmental design was used to examine whether current levels of child picky eating, parental use of pressure, and SEP were associated with changes in WFL during infancy. Health providers distributed survey packets during routine well-child visits made in the homes of families with young children in New Zealand (n = 193). Primary caregivers of young children provided their child's current level of picky eating, their use of pressure, and their SEP. They also reported their child's professionally-measured WFL from birth, 8, 15, and 21 months of age. A multi-level modeling analysis yielded an interaction between SEP and picky eating in predicting infant weight change over time. Children who had a low SEP and were not picky eaters were on the highest WFL trajectory and children who had a low SEP and were picky eaters were lowest on the WFL trajectory. A main effect revealed that higher levels of parental pressure predicted lower WFL in infants at each age, but did not interact with SEP or picky eating. Findings from this study indicate that the combination of eating behavior and SEP are associated with differential infant growth patterns. These results suggest that eating behavior and SEP should be included in the development of interventions designed to achieve healthy weight during childhood.

Differences in early risk factors for obesity between African American formula-fed infants and White breastfed controls

Background

Previous RCTs to prevent early rapid weight gain were conducted in predominantly White, well-educated, middle-income mother-infants at low risk for obesity. To inform the design of an RCT in a higher-risk sample, we conducted a short-term, longitudinal study to compare maternal feeding beliefs and behaviors, infant sleep, intake, and growth of African American formula feeding (AAFF) dyads to a comparison sample of White breastfeeding (WBF) dyads. We also assessed the feasibility of recruiting and retaining AAFF participants.

Methods

AAFF (n = 32) and WBF (n = 25) mother-infants were assessed at 2, 8, and 16 weeks postpartum. Data included demographics and maternal reports of feeding beliefs and behaviors, infant sleep, meal size, and feeding frequency, and measured infant length and weight.

Results

AAFF and WBF mothers differed in demographics. AAFF mothers reported greater agreement with pressuring the infant to eat and feeding to soothe a fussy infant. Compared to WBF infants, AAFF infants slept fewer hours and consumed more grams/feeding from 2 to 16 weeks. There were no group differences in feeding frequency, which resulted in AAFF infants consuming more grams/day of milk than WBF infants. AAFF infants had lower gestational age, lower weight at 2 weeks, and had more rapid weight gain from 8 to 16 weeks.

Conclusions

Findings point to potentially modifiable risk factors that may underlie disparities in early obesity among AAFF infants, including short sleep duration, feeding beliefs and behaviors, and rapid growth, but also confirm the challenges of recruiting and retaining AAFF participants, all of which inform the design and feasibility of an early preventive intervention.

Trial registration

Retrospectively registered in clinicaltrials.gov on August 23, 2016 (2013102510).

Testing the direction of effects between child body composition and restrictive feeding practices: results from a population-based cohort

Background: Parental restrictive feeding (i.e., limiting food intake of children) has been linked to childhood overweight. However, the directionality of the causal pathway remains unknown.Objective: The objectives of this study were to examine the bidirectional association of maternal restrictive feeding with children's weight and body composition across childhood and to explore a possible mediating role of maternal concern about child weight.Design: Data were available for 4689 mother-child dyads participating in Generation R, a prospective birth cohort in the Netherlands. At ages 4 and 10 y, restrictive feeding was assessed with the parent-reported Child Feeding Questionnaire, and children's body mass index (BMI) was measured. At age 6 y, fat mass index (FMI) and fat-free mass index (FFMI) were measured with dual-energy X-ray absorptiometry. Both directions of the relation between restriction and child body composition were examined with multivariable linear regression analyses and cross-lagged modeling. Mediation analyses were performed to examine concern about child weight (mother reported at child age of 10 y) as a potential mediator.Results: Higher child sex- and age-adjusted BMI SD scores (zBMI) at age 4 y predicted more restrictive feeding at age 10 y (B = 0.15; 95% CI: 0.11, 0.18). Both sex- and age-adjusted FMI SD scores (zFMI) and sex-and age-adjusted FFMI SD scores (zFFMI) at 6 y were also positively associated with restrictive feeding at 10 y. Maternal concern about child weight partially mediated these associations from child body composition to restrictive feeding (e.g., for zBMI at 4 y: B_indirect = 0.10; 95% CI: 0.07, 0.13). There was no temporal association from restrictive feeding at age 4 y to child zBMI at age 10 y after adjustment for baseline zBMI.Conclusions: The continued use of restrictive feeding practices at age 10 y appeared to be primarily a response of mothers to an unhealthy weight of their child rather than a cause of children's overweight. Guidelines discouraging restrictive feeding for preventing childhood overweight should therefore be reconsidered.

Consumption of key food groups during the postpartum period in low-income, non-Hispanic black mothers

The postpartum period can impact diet quality and subsequently place women at greater risk for overweight or obesity. This study examined consumption of key food groups during the first 2 years postpartum among low income, non-Hispanic black, first-time mothers. Data were from the Infant Care, Feeding and Risk of Obesity Study, a cohort of 217 mother-infant dyads, followed from 3 to 18 months postpartum, collected from 2003 to 2007. At each study visit (3, 6, 9, 12, and 18 months) 24-h dietary recalls were collected. Consumption levels were compared to those recommended from the 2010 Dietary Guidelines for Americans (DGAs) for each of the following food groups: fruits, vegetables, grains, whole grains, protein foods and dairy, as well as an estimated upper limit for sugar-sweetened beverage (SSB) consumption. At each time point, mothers met recommended intake levels for grains and protein foods only. In random-intercept logistic regression models, no demographic or household characteristics were associated with a likelihood of consuming recommended levels for any of the food groups according to the DGAs. Given the low intake of fruits, vegetables, whole grains and lean protein foods and high intake of SSBs and refined grains, interventions targeting women's diet during the postpartum period are warranted.

Family-based obesity prevention for infants: Design of the "Mothers & Others" randomized trial

OBJECTIVE

Our goal is to test the efficacy of a family-based, multi-component intervention focused on infants of African-American (AA) mothers and families, a minority population at elevated risk for pediatric obesity, versus a child safety attention-control group to promote healthy weight gain patterns during the first two years of life.

DESIGN, PARTICIPANTS, AND METHODS

The design is a two-group randomized controlled trial among 468 AA pregnant women in central North Carolina. Mothers and study partners in the intervention group receive anticipatory guidance on breastfeeding, responsive feeding, use of non-food soothing techniques for infant crying, appropriate timing and quality of complementary feeding, age-appropriate infant sleep, and minimization of TV/media. The primary delivery channel is 6 home visits by a peer educator, 4 interim newsletters and twice-weekly text messaging. Intervention families also receive 2 home visits from an International Board Certified Lactation Consultant. Assessments occur at 28 and 37weeks gestation and when infants are 1, 3, 6, 9, 12, and 15months of age.

RESULTS

The primary outcome is infant/toddler growth and likelihood of overweight at 15months. Differences between groups are expected to be achieved through uptake of the targeted infant feeding and care behaviors (secondary outcomes) and change in caregivers' modifiable risk factors (mediators) underpinning the intervention.

CONCLUSIONS

If successful in promoting healthy infant growth and enhancing caregiver behaviors, "Mothers and Others" will have high public health relevance for future obesity-prevention efforts aimed at children younger than 2years, including interventional research and federal, state, and community health programs.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01938118, August 9, 2013.

Longitudinal associations between maternal feeding and overweight in low-income toddlers

Maternal feeding is a frequent intervention target for the prevention of early childhood obesity but longitudinal associations between feeding and child overweight are poorly understood. This observational cohort study sought to examine the cross-lagged associations between maternal feeding and overweight across ages 21, 27, and 33 months. Feeding was measured by maternal self-report (n = 222) at each age. Child weight and length were measured. Cross-lagged analysis was used to evaluate longitudinal associations between feeding and overweight, adjusting for infant birth weight, maternal body mass index, maternal education, and maternal depressive symptoms. The sample was 50.5% white, 52.3% male and 37.8% of mothers had a high school education or less. A total of 30.6%, 29.2%, and 26.3% of the sample was overweight at each age, respectively. Pressuring to Finish, Restrictive with regard to Amount, Restrictive with regard to Diet Quality, Laissez-Faire with regard to Diet Quality, Responsiveness to Satiety, Indulgent Permissive, Indulgent Coaxing, Indulgent Soothing, and Indulgent Pampering each tracked strongly across toddlerhood. There were no significant associations between maternal feeding and child overweight either in cross-sectional or cross-lagged associations. Our results do not support a strong causal role for feeding in childhood overweight. Future work longitudinal work should consider alternative approaches to conceptualizing feeding and alternative measurement approaches.

An Experimental Approach to Study Individual Differences in Infants' Intake and Satiation Behaviors during Bottle-Feeding

BACKGROUND

As a group, bottle-fed infants are at higher risk for rapid weight gain compared with breast-fed infants. However, little is known about individual differences in feeding behaviors of bottle-feeding infants, as well as maternal and infant characteristics associated with bottle-feeding outcomes.

METHODS

We conducted a 2-day, within-subject study of 21 formula-feeding dyads; the within-subject factor was feeding condition: mother-led (ML; mothers were given the instruction to feed their infants as they typically would) vs. infant-led (IL; the experimenter ensured feeding began when infants signaled hunger and ended when they rejected the bottle on three consecutive occasions). Intake was determined by bottle weight; feedings were video-recorded and later analyzed to determine feeding duration and types of satiation behaviors displayed. Percent difference scores were calculated for each outcome as [((ML - IL)/IL) × 100] to standardize differences among dyads. Mothers completed questionnaires of feeding styles and infant temperament.

RESULTS

On average, infants consumed ∼42% more formula during the ML- than IL-condition (p = 0.03). However, notable variation existed in difference scores for intake (range = -52.8% to 268.9%; higher scores reflect greater intake during ML than IL). Stepwise regression illustrated that greater intakes during the ML-condition were predicted by the combination of: (1) higher infant age; (2) lower levels of infant rhythmicity and adaptability; (3) higher levels of infant positive mood; and (4) lower levels of maternal restrictive and responsive feeding styles.

CONCLUSIONS

This objective, experimental approach illustrated that variation in bottle-feeding outcomes is associated with characteristics of both members of the dyad.

Maternal Beliefs Surrounding Infant Feeding, but Not Maternal BMI or Hospital Experience, Predict Breastfeeding Exclusivity and Behavior

BACKGROUND

Overweight/Obese (OW/Ob) women are at risk for breastfeeding failure. How maternal BMI affects lactation support received in-hospital, or maternal attitudes and beliefs surrounding infant feeding remains poorly understood. We investigated 1) the impact of in-hospital lactation support and maternal attitudes and behaviors regarding infant feeding on breastfeeding exclusivity, and 2) whether these potentially modifiable attitudes and behaviors differed between normal weights (NW) versus OW/Ob women.

METHODS

NW (n=18) and OW/Ob (n=20) women and their infants were followed from birth to 4-months postpartum. In-hospital experiences, problems and help received regarding breastfeeding were documented. Six maternal attitudes and behaviors surrounding infant feeding were assessed at 2-weeks and 4-months. These factors were compared between NW and OW/OB women, and in relation to breastfeeding exclusivity.

RESULTS

In-hospital experiences, assistance received regarding breastfeeding difficulties, and infant breastfeeding exposure did not differ between NW and OW/Ob women. At 4-months OW/Ob women were more likely to feed their infant on a schedule (p<0.03); this was the only difference in attitudes/behaviors between BMI-groups. Feeding the infant on a schedule was predictive of lower total breastfeeding exposure (p<0.05). Maternal concern about infant under-eating/becoming underweight was associated with several negative feeding behaviors, including reduced breastfeeding exposure (p<0.02), pressuring feeding style (p<0.01), and feeding to calm fussiness (p<0.01).

CONCLUSION

This hospital setting provided equitable breastfeeding support to OW/Ob and NW women. Maternal concern over infant under-eating/under-gaining and encouragement to feed on-demand are prime interventional targets to improve breastfeeding outcomes; the latter may be especially relevant to OW/Ob mothers.