Providers' response to child eating behaviors: A direct observation study

'For me it's just the conversation:' responsive feeding influences among early childhood educators

OBJECTIVE

Early learning and childcare (ELCC) programmes play an important role in shaping children's eating behaviours and long-term health by establishing a responsive feeding environment that encompasses not only mealtime behaviours but also extends to play activities and language used throughout the day. Despite their potential benefits, many ELCC centres do not consistently implement responsive feeding behaviours, facing challenges with organisational and behavioural changes within these environments. This study aims to identify influences on responsive feeding behaviours among early childhood educators prior to an intervention.

DESIGN

A qualitative study guided by the Behaviour Change Wheel framework and Capability Opportunity Motivation - Behaviour (COM-B) model. Semi-structured interviews and focus groups were conducted, recorded and transcribed verbatim. Thematic analysis was employed to identify themes, categorising them within the corresponding COM-B domains.

SETTING

Canada.

PARTICIPANTS

Forty-one ELCC staff in various roles across eight centres from two provinces in eastern Canada.

RESULTS

Fifteen influences, spanning across all six domains of the COM-B model, were identified, highlighting gaps in educators' knowledge and skills, varied approaches to food and feeding, and the interactions with children, parents, and co-workers on mealtimes dynamics. Additionally, costs, centre location and other physical resources emerged as enabling opportunities for responsive feeding behaviours.

CONCLUSIONS

These findings offer a comprehensive exploration of the diverse factors influencing responsive feeding behaviours among educators, each varying in its potential for future behaviour change intervention.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Testing the effects of interventions designed to increase children's consumption of fruit and vegetables, including those focused on specific child-feeding strategies or broader multicomponent interventions targeting the home or childcare environment, is required to assess the potential to reduce this disease burden.

OBJECTIVES

To assess the benefits and harms of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 March 2023. We searched Proquest Dissertations and Theses in December 2022. We reviewed reference lists of included trials and contacted authors of the included trials to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), including cluster-randomised controlled trials (C-RCTs) and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both amongst children aged five years and under compared to no-intervention control, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. We used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the certainty of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 53 trials with 120 trial arms and 12,350 participants. Sixteen trials examined the impact of child-feeding practice interventions only (e.g. repeated food exposure) in increasing child vegetable intake. Twenty trials examined the impact of multicomponent interventions primarily conducted in the childcare setting (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Seventeen trials examined the impact of parent nutrition education only in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children only in increasing child fruit and vegetable intake and one each examined a child-focused mindfulness intervention or providing families with fruit and vegetable interventions. We judged nine of the 53 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is moderate-certainty evidence that child-feeding practice interventions versus no-intervention control probably have a small positive effect on child vegetable consumption, equivalent to an increase of 15.5 grams as-desired consumption of vegetables (SMD 0.44, 95% confidence interval (CI) 0.24 to 0.65; 15 trials, 1976 participants; mean post-intervention follow-up = 12.3 weeks). No trials in this comparison reported information about intervention costs. One trial reported no harms or serious unintended adverse consequences (low-certainty evidence). Multicomponent interventions versus no-intervention control probably have a small effect on child consumption of fruit and vegetables (SMD 0.27, 95% CI 0.11 to 0.43; 14 trials, 4318 participants; moderate-certainty evidence; mean post-intervention follow-up = 4.0 weeks), equivalent to an increase of 0.34 cups of fruit and vegetables a day. One trial, which tested a multicomponent garden-based intervention, reported the installation of the garden as part of the intervention to be USD 1500 per childcare centre (low-certainty evidence). No trials in this comparison reported information about unintended adverse consequences of interventions. Parent nutrition education interventions may have little to no short-term impact on child consumption of fruit and vegetables versus no-intervention control (SMD 0.10, 95% CI -0.02 to 0.22; 14 trials, 4122 participants; low-certainty evidence; mean post-intervention follow-up = 6.4 weeks). One trial reported the total estimated cost of delivering a parent nutrition education intervention for infant feeding, physical activity and sedentary behaviours delivered by a dietitian as approximately AUD 500 per family (low-certainty evidence). One trial reported no unintended adverse consequences on family food expenditure following implementation of an intervention delivered over the telephone to improve parental knowledge and skills about the home food environment (low-certainty evidence). Trials reported receiving governmental or charitable funds, except for one trial reporting industry funding.

AUTHORS' CONCLUSIONS

There was moderate-certainty evidence that child-feeding practice interventions and multicomponent interventions probably lead to only small increases in fruit and vegetable consumption in children aged five years and under. Parent nutrition education interventions may have little or no effect on increasing fruit and vegetable consumption in children aged five years and under. Future research should be prioritised on assessment and reporting of both intervention cost and adverse effects, and development and evaluation of interventions in research gaps, including in a broader range of settings and in low- and middle-income countries. This review continues to be maintained as a living systematic review with monthly searches for new evidence and incorporation of relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Obesity in childhood: associations with parental neglect, nutritional habits, and obesity awareness

Background

The relationships underlying the dynamic between obesity and parental neglect in terms of nutritional habits and obesity awareness are unclear. Parental neglect remains a significant subject of concern that needs to be examined in the context of obesity.

Methods

The aim was to examine the relationships between childhood obesity, parental neglect, children's eating habits and obesity. The study group consisted of 404 children and their parents from Ankara, Turkiye. As data collection tools, an Individual Information Form, Obesity Awareness Scale, the Parents Form of the Multidimensional Neglectful Behaviors Scale were administered. In addition, information on the children's body mass indexes was obtained by anthropometric measurements and the findings were recorded on the questionnaires of each child.

Results

It was found that 98 (24.3%) of the children included in the study were overweight and 63 (15.6%) were obese. The results of the multinomial logistic regression analysis indicated that in the underweight and overweight group, the parents' perception of their child's weight predicted body mass index in children, and in the obese group, along with the parents' perception of their child's weight, the age and gender of the child, eating fast, obesity in the family and parental neglect were also predictors.

Conclusion

Practitioners such as nurses, dietitians and child developmentalists working in schools should consider weight problems in children as one of the indicators of parental neglect and should implement interventive efforts to enhance parental supervision of children at risk.

Advancing assessment of responsive feeding environments and practices in child care

Child care environments offer an ideal setting for feeding interventions. CELEBRATE Feeding is an approach implemented in child care environments in two Maritime Provinces in Canada to support responsive feeding (RF) to foster children's self-efficacy, self-regulation, and healthy relationships with food. This study aimed to describe RF in child care using established and enhanced scoring frameworks. The Environment and Policy Assessment and Observation (EPAO) was modified to reflect RF environments and practices, resulting in our modified EPAO and a CELEBRATE scale. Observations were conducted in 18 child care rooms. Behaviours and environments were scored on both scales, creating 21 RF scores, with a score of '3' indicating the most responsiveness. Descriptive analyses of the scores were conducted. The overall room averages were Mean (M) = 41.00, Standard Deviation (SD) = 7.07 (EPAO), and M = 37.92 SD = 6.50 (CELEBRATE). Most responsive scores among rooms within our EPAO and CELEBRATE scales, respectively, were 'educators not using food to calm or encourage behaviour' (M = 2.94, SD = 0.24; M = 2.98, SD = 0.06) and 'not requiring children to sit at the table until finished' (M = 2.89, SD = 0.47; M = 2.97, SD = 0.12). The least responsive scores within the EPAO were 'educator prompts for children to drink water' (M = 0.78, SD = 0.94) and 'children self-serving' (M = 0.83, SD = 0.38). The least responsive in the CELEBRATE scale were 'enthusiastic role modelling during mealtime' (M = 0.70, SD = 0.68) and 'praise of mealtime behaviour unrelated to food intake' (M = 0.74, SD = 0.55). The CELEBRATE scale captured unique observation information about RF to allow documenting change over time with detailed measurement to inform and support nutrition interventions within child care environments.

Young Children's Dietary Quality in Family Child Care and in Their Own Home

BACKGROUND

Some evidence suggests that children may have higher quality dietary intake in early care and education settings, compared with their respective homes, but no studies have explored these differences among children in less formal family child care.

OBJECTIVE

The purpose of this study was to compare dietary quality via the Healthy Eating Index 2015 among children in family child care and in their own home.

DESIGN

This was a cross-sectional analysis of baseline dietary intake data from the Childcare Home Eating and Exercise Research study, a natural experiment, using directly observed dietary data in child care and 24-hour recall data in homes among children in South Carolina.

PARTICIPANTS/SETTING

Participants were 123 children in 52 family child-care homes between 2018 and 2019.

MAIN OUTCOME MEASURE

The main outcome was total and component Healthy Eating Index 2015 scores.

STATISTICAL ANALYSIS

The analysis was a hierarchical linear regression of children nested within family child care homes adjusting for child, provider, facility, and parent characteristics, including sex, age, race, ethnicity, and income, with parameters and SEs estimated via bootstrap sampling.

RESULTS

Children had a mean ± SD Healthy Eating Index 2015 score of 60.3 ± 12.1 in family child-care homes and 54.3 ± 12.9 in their own home (P < 0.001). In adjusted analysis and after accounting for clustering of children in family child care homes, total HEI-2015 scores were lower at home than in care (β = -5.18 ± 1.47; 95% CI -8.05 to -2.30; P = 0.003).

CONCLUSIONS

Children had healthier dietary intake in family child-care homes vs their respective homes.

Diet-Related Disparities and Childcare Food Environments for Vulnerable Children in South Korea: A Mixed-Methods Study

Diet-related disparities that have often been observed in vulnerable families may play a negative role in children's health and health-related quality of life. In South Korea, an afterschool care policy, called Community Childcare Center (CCC), was established in the 1960s to protect and educate vulnerable children; this role has expanded to provide meal services in recent times. Therefore, the CCCs' food environment has become a pivotal platform for observing children's nutrition and health-related disparities. Using a mixed-methods approach including a survey with self-reported questionnaires, field observation, and participant interviews, the food environment of CCC was explored alongside children's eating behaviors. Eating behaviors were not as healthy as expected. Although service providers and cooks reported in the survey responses that the centers' food environment was healthy, participant observations and interviews revealed a significant gap. Establishing a standardized food environment and improving the nutrition literacy of workers as a significant human resource at a CCC can promote healthy eating for vulnerable children. The findings suggest that in the absence of steps to improve the food environment of CCC, diet-related disparities may affect children's health in the future.

Predictors of Overweight and Obesity in Early Care and Education Teachers during COVID-19

The purpose of this cross-sectional study was to determine individual, sociocultural, policy, and economic predictors of overweight/obesity in early care and education (ECE) teachers to identify modifiable opportunities to enhance the health of this critical workforce. ECE teachers (n = 1434) in the U.S. completed an online survey in late spring to mid-summer 2020. Teachers self-reported height and weight; body mass index (BMI) and weight status were calculated. Teachers reported micro-environment variables including age, race, gender, obesogenic lifestyle behaviors, well-being, food security, personal health, stress, job stress, type of ECE, COVID-19 teaching modality, and age of children in the classroom. Logistic regression predicting overweight/obesity and linear regression predicting BMI were conducted. Teachers with more years of teaching experience (OR: 1.022: 95% CI 1.005, 1.039) and higher consumption of fast food (2.038: 1.310, 3.169) had higher odds of overweight/obesity. Teachers with higher levels of education (0.58: 0.407, 0.828) and higher physical health (0.836: 0.775, 0.902) had lower odds of overweight/obesity. Other variables were not associated with overweight/obesity. Variables significant in logistic regression were also associated with higher BMI. Additionally, Native American race (β = 2.467 SE = 1.206) and sedentary hours/day (β = 0.152 SE = 0.075) were associated with higher BMI. Implications for enhancing workplace health for these ECE teachers are emerging.

Strategies and behaviors used by mothers in interactions with their young children during a mealtime in peri-urban areas of Huánuco, Peru

This study aimed to gain an in-depth understanding about different strategies used by mothers to feed their 6-23-month-old children, as well as to learn about mothers' behaviors in response to situations of food refusal by her child, in order to generate evidence that contributes to the information gap on responsive feeding in Peru. The study was conducted in the city of Huánuco, a peri-urban area of Peru, with mothers of children in the complementary feeding stage participating. An in-depth 5-hour home observation was conducted in eight mother-child dyads. Both the mothers' and children's mealtime and food-related behaviors were coded and an inductive thematic analysis was applied. The primary objective of many of the strategies used by the mothers was to get their child to eat a little more. Six strategies were identified: pressure, encouragement, facilitating intake, acceptance, negotiation and reasoning. Certain differences were found in the strategies employed by the mother according to the age of her child, with mothers of younger children using more encouragement and mothers of older children using more pressure for their child to eat. The mothers' behavior in response to the child's refusal of food was both responsive and non-responsive (controlling), depending on the reason for the refusal. The findings are of great value for understanding about the feeding interactions of mother-child dyads in Peru and they start to address the information gap and can support the development of nutritional intervention strategies for use with children.

Mixed-method assessment of caregiver feeding practices in early care and education centres during COVID-19

OBJECTIVE

The COVID-19 pandemic changed early care and education (ECE) mealtimes. Feeding practices that support children's emerging autonomy may support children's healthy eating, but it is unknown whether and how COVID-19 changed feeding practices. This paper describes caregiver feeding practices in ECE centres in Florida during COVID-19.

DESIGN

A mixed-methods design was used to understand mealtime feeding practices. Survey and interview questions were developed based on the Trust Model. More than 7000 surveys were sent to ECE centres. Analysis included descriptive statistics for survey data and thematic analysis for interview data.

SETTING

This statewide study included teachers in all licensed and license-exempt ECE centres.

PARTICIPANTS

Four hundred and thirty-one teachers completed a survey, and twenty-nine participated in follow-up interviews.

RESULTS

Surveys showed most teachers engaged in autonomy-supportive behaviours, such as letting children eat until they were finished (90 %). The most common controlling behaviour was praising children for cleaning their plates (70 %). The most common responses about changes to mealtimes were keeping physical distance and serving healthy food. Interview themes were Autonomy Support, Controlling Feeding Practices, Interactions are the Same, Interactions are Different, Physical Distancing and Healthy Eating.

CONCLUSIONS

Mealtimes are a central part of the day for young children and teachers in ECE environments. COVID-19 continues to influence ECE routines as behaviour change remains the primary method of reducing the risk of COVID-19 in the absence of a vaccine for young children. Understanding teachers' practices and perspectives is important for reducing the risk of COVID-19 and supporting children's autonomy and healthy eating.

Ecological Approach to Family-Style, Multilevel Child Care Intervention: Formative Evaluation Using RE-AIM Framework

OBJECTIVE

Conduct formative evaluation of Ecological Approach to Family-Style Dining (EAT) Intervention.

DESIGN

Qualitative semistructured interviews and demographic surveys.

SETTING

Early care and education (ECE) centers in Nebraska.

PARTICIPANTS

Cooperative Extension coaches (n = 9), ECE administrators (n = 8), and teachers (n = 17) caring for children aged 3-5 years.

INTERVENTION

The EAT intervention (a 16-week, 7-lesson, evidence-based online responsive feeding ECE model) uses a multilevel improvement system of 5 implementation strategies. Early care and education administrators and teachers completed 1 lesson/wk followed by a coaching session.

MAIN OUTCOME MEASURES

The Reach, Effectiveness, Adoption, Implementation, and Maintenance framework includes 5 evaluative dimensions.

ANALYSIS

Thematic analysis.

RESULTS

Overall, 77% of children aged 3-5 years (n = 216) participated from targeted Child and Adult Care Food Program ECEs (Reach). All perceived EAT improved children's nutritional and developmental outcomes and encouraged a positive mealtime environment (Effectiveness). Coaches found professional development incentives important, whereas administrators/teachers valued inservice hours (Adoption). Teachers reported successful implementation of responsive feeding, and administrators supported the teachers (Implementation). All reported they intended to continue using EAT, and administrators and teachers discussed incorporating EAT practices into the handbook/school policy (Maintenance).

CONCLUSION AND IMPLICATIONS

The EAT was valued by all stakeholders for its perceived effectiveness to positively impact children's nutritional outcomes. Furthermore, stakeholders valued the provided incentives and multilevel design with coaching, ECE administrators, and teachers. Future research is needed on how to use Extension coaches in ECE interventions.

Food Desert Status of Family Child Care Homes: Relationship to Young Children's Food Quality

Family child care homes (FCCHs) are a favored child care choice for parents of young children in the U.S. Most FCCH providers purchase and prepare foods for the children in their care. Although FCCH providers can receive monetary support from the Child and Adult Care Food Program (CACFP), a federal subsidy program, to purchase nutritious foods, little is known about FCCH providers' access to nutritious foods, especially among FCCH providers serving children from communities that have been historically disinvested and predominantly Black. This study aims to describe the food desert status of FCCHs in Baltimore City, Maryland, and examine the relationship between food desert status and the quality of foods and beverages purchased and provided to children. A proportionate stratified random sample of 91 FCCH providers by CACFP participation status consented. Geographic information system mapping (GIS) was used to determine the food desert status of each participating FCCH. Participants reported on their access to food and beverages through telephone-based surveys. Nearly three-quarters (66/91) of FCCHs were located in a food desert. FCCH providers working and living in a food desert had lower mean sum scores M (SD) for the quality of beverages provided than FCCH providers outside a food desert (2.53 ± 0.81 vs. 2.92 ± 0.70, p = 0.036, respectively). Although the significant difference in scores for beverages provided is small, FCCH providers working in food deserts may need support in providing healthy beverages to the children in their care. More research is needed to understand food purchases among FCCH providers working in neighborhoods situated in food deserts.

"Just sit and eat." Adult and Child Mealtime Responsibilities in Early Care and Education Centers During COVID-19 in Florida

Most young children in the United States attend early care and education (ECE) programs, in which they eat 3-4 times daily. 'Division of responsibility' between adult and child means the adults are responsible for what, when and where, and the child is responsible for whether, what and how much to eat. A balanced division of responsibility can support children's development of healthy eating competency. This paper aims to describe division of responsibility during mealtimes during COVID-19 in Florida using a cross-sectional, mixed methods design. Questions were developed based on Trust Model and Social Cognitive Theory. A survey was completed by 759 ECE directors and 431 teachers, and 29 teachers completed in-depth interviews. COVID-19 increased teacher mealtime responsibilities. Most (95%+) ECE teachers provided meals at the same time and place daily (when and where). Children determined what and how much they ate, but did not serve or handle food. Implications include modifying mealtime routines to minimize the risk of COVID-19 and support healthy eating with a balanced division of responsibility.

Assessment of Feeding Practices and Mealtime Environments in Australian Family Daycare Services

OBJECTIVE

Assess educators' feeding practices and mealtime environments in family daycare services and examine the factors associated with educators' feeding practices and mealtime environments.

METHODS

Cross-sectional observational study of family daycare services (n = 33) in Australia. Best practices for mealtime environments and educator feeding practices were assessed during each mealtime using the Environment Policy Assessment and Observation instrument. Correlates assessed via survey included: socioeconomic status, main language spoken at home, early childhood career experience, and nutrition professional development. Descriptive statistics and independent t tests were calculated.

RESULTS

Educators typically had higher scores, indicating better practices, for (the absence of) negative practices compared with positive practices. The only positive practice meeting best-practice standards was educators sitting with children during the meal. There were no significant correlations for educators' feeding practices or mealtime environment.

CONCLUSIONS AND IMPLICATIONS

Educators may benefit from professional development targeting positive feeding practices and supportive mealtime environments.

Mealtime Environment and Feeding Practices in Urban Family Child Care Homes in the United States

Background: Family Child Care Homes (FCCHs) are the second-largest childcare option in the US. Given that young children are increasingly becoming overweight and obese, it is vital to understand the FCCH mealtime environment. There is much interest in examining the impact of the Child and Adult Care Food Program (CACFP), a federal initiative to support healthy nutrition, by providing cash reimbursements to eligible childcare providers to purchase nutritious foods. This study examines the association among the FCCH provider characteristics, the mealtime environment, and the quality of foods offered to 2-5-year-old children in urban FCCHs and examines the quality of the mealtime environment and foods offered by CACFP participation. Methods: A cross-sectional design with a proportionate stratified random sample of urban FCCHs by the CACFP participation status was used. Data were collected by telephone using the Nutrition and Physical Activity Self-Assessment for Child Care survey. Results: A total of 91 licensed FCCHs (69 CACFP, 22 non-CACFP) participated. FCCH providers with formal nutrition training met significantly more of the quality standards for foods offered than providers without nutrition training (β = 0.22, p = 0.034). The mealtime environment was not related to any FCCH provider characteristics. CACFP-participating FCCH providers had a healthier mealtime environment (β = 0.326, p = 0.002) than non-CACFP FCCHs. Conclusions: Findings suggest that nutrition training and CACFP participation contribute to the quality of nutrition-related practices in the FCCH. We recommend more research on strengthening the quality of foods provided in FCCHs and the possible impact on childhood obesity.

Food insecurity, food parenting practices, and child eating behaviors among low-income Hispanic families of young children

Food insecurity is associated with negative food parenting practices that may promote child obesity, including pressure to eat and food restriction. Less is known about the relationship between food insecurity and positive food parenting practices, including exposing the child to new foods and involving the child in food preparation. Further, few studies have investigated the associations between food insecurity and child eating behaviors that have been linked to poor dietary outcomes. Using baseline data collected as part of a larger pilot intervention, we examined the relationships between food security status, food parenting practices, and child eating behaviors in a predominately Hispanic, low-income sample of parents and their preschool aged children (n = 66). Between July of 2019 and 2020, caregivers recruited from 4 urban communities in Rhode Island completed assessments of household food security, food parenting practices, and four child eating behaviors: food responsiveness, emotional overeating, enjoyment of food, and satiety responsiveness. Although 46% of caregivers reported food insecurity, food insecurity was not directly associated with any food parenting practice. Children in food insecure households were rated as higher in levels of food responsiveness and enjoyment of food as compared to children in food secure households. Children in food insecure households were rated as lower in satiety responsiveness as compared to children in food secure households. Child emotional overeating did not vary by food security status. Future interventions to reduce child obesity among low-income Hispanic families should assess food security status and consider any level of food insecurity as a potential signal of unhealthy child eating behaviors.

Child meal microstructure and eating behaviors: A systematic review

Observational coding of children's eating behaviors and meal microstructure (e.g., bites, chews) provides an opportunity to assess complex eating styles that may relate to individual differences in energy intake and weight status. Across studies, however, similar terms are often defined differently, which complicates the interpretation and replication of coding protocols. Therefore, this study aimed to compile methods of coding meal microstructure in children. To limit bias and ensure a comprehensive review, a systematic search was conducted in January 2021 across three databases (PubMed, PsychInfo, Web of Science) resulting in 46 studies that coded at least one meal-related behavior in healthy children (i.e., no medical/psychological disorders) who were able to self-feed (i.e., no spoon-, breast-, or bottle-feeding). While the majority of studies had good interrater reliability, the details reported about study foods and the clarity of the definitions used for behavioral coding varied considerably. In addition to reported microstructure behaviors, a non-exhaustive review of individual differences was included. While few studies reported individual differences related to age and sex, there was a larger literature related to weight status that provided evidence for an 'obesogenic' style of eating characterized by larger Bites, faster Eating and Bite Rates, and shorter Meal Durations. However, some studies may not have been optimally designed or powered to detect individual differences because they did not set out a priori to examine them. Based on this systematic review, best practices for the field are recommended and include reporting more details about foods served and coded eating behaviors to improve reproducibility. These suggestions will improve the ability to examine patterns of individual differences across studies, which may help identify novel targets for intervention.

Associations between food provision and feeding practices in socially disadvantaged childcare centres

Preschool children consume a large proportion of their daily food intake in their childcare settings. These settings, therefore, provide important opportunities for children to experience food socialisation, and related positive nutrition. Yet, the extent to which these opportunities are taken, particularly in socioeconomically disadvantaged areas where risk of poor nutrition is high, is not well documented. This study focused on 10 childcare centres in socially disadvantaged locations and examined daily feeding practices via direct in-situ observation (n = 189 children observed). Centres were randomly selected based on type of food provision: centre-provided (n = 5 centres) or family-provided (n = 5 centres). Analyses showed that where food was family-provided, educators were significantly more likely to use controlling feeding practices, including pressuring children to eat, restricting food choices and rushing children into finishing meals. These practices were particularly evident during mid-morning meals, where pressuring children to eat healthy foods first, was more often observed. Further research and interventions that target feeding practices in childcare are indicated and should consider how source of food provision impacts upon these practices.

Comparison of Japanese and Scottish Mother-Infant Intersubjectivity: Resonance of Timing, Anticipation, and Empathy During Feeding

Feeding involves communication between mothers and infants and requires precise synchrony in a special triadic relationship with the food. It is deeply related to their intersubjectivity. This study compared the development of mother-infant intersubjectivity through interactional synchrony in feeding between 11 Japanese and 10 Scottish mother-infant dyads, observed at 6 and 9 months by video. Japanese mothers were more deliberate in feeding at an earlier age, whereas Scottish mothers were significantly more coercive than Japanese mothers at an earlier age. Japanese mothers brought the spoon to infants with a pause to adjust the timing of insertion to match their infants' readiness, whereas this pause was not observed in Scottish mothers. Isomorphic mouth opening between mothers and infants was observed. This empathic maternal display is an important element of intersubjectivity in infant feeding that differed between Scottish and Japanese mothers. Scottish mothers' mouth opening always followed their infants' mouth opening, but about half of Japanese mothers preceded their infants. Further, the mouths of Scottish infants and mothers opened almost at the same time as spoon insertion. In contrast, Japanese mothers' mouth opening did not co-occur with the insertion but was close to spoon arrival, a subtle but important difference that allows for greater infant autonomy. The time structure of Scottish mother-infant interactions was simpler and more predictable at 9 months than in Japan, where the structure was more variable, likely due to a stronger regulation by Scottish mothers. In conclusion, Scottish mother-infant intersubjectivity is characterized as more maternally reactive and mother-centered, whereas Japanese mother-infant intersubjectivity is characterized as more maternally empathetic and infant-centered. Cultural differences in intersubjectivity during feeding between Japan and Scotland are further discussed in relation to triadic relationships and parenting styles.

Ethnic Differences in Family Childcare Providers' Nutrition- and Activity-Related Attitudes and Barriers

Objective

The aim of the study is to examine family childcare providers' (FCCPs) attitudes and perceived barriers related to nutrition, physical activity (PA), and screen time (ST) behaviors of preschool children, exploring differences by provider ethnicity.

Design

Baseline survey data from a cluster-randomized trial. Participants. Around 168 FCCPs completed a telephone survey, and 126 completed both telephone and in-person surveys. Main Outcome Measures. Phone and in-person surveys include 44 questions to assess FCCPs attitudes and perceived barriers regarding nutrition, PA, and ST in the family childcare home. Analysis. Associations by ethnicity (Latinx vs. non-Latinx) were assessed by ANOVA, adjusting for provider education and Bonferroni correction.

Results

Some FCCP attitudes were consistent with national obesity prevention guidelines; for example, most FCCPs agreed that they have an important role in shaping children's eating and PA habits. However, many FCCPs agreed with allowing children to watch educational TV and did not agree that children should serve themselves at meals. Adjusting for education, there were statistically significant differences in attitude and perceived barrier scores by provider ethnicity. For example, Latinx FCCPs were more likely to agree that they should eat the same foods as children(p < .001) but less likely to agree that serving the food at meal and snack time is the adult's responsibility (p < .001). Latinx FCCPs were more like to perceive barriers related to children's safety playing outside (p < .001). Conclusions and Implications. While FCCPs hold some nutrition-, PA-, and ST-related attitudes consistent with national guidelines, training opportunities are needed for FCCPs to improve knowledge and skills and overcome perceived barriers related to nutrition and PA. Latinx FCCPs, in particular, may need culturally tailored training and support to overcome misperceptions and barriers.

Food practices and nutrition of children and adolescents in residential care: A scoping review

Food practices of children and adolescents have thus far been researched mainly regarding families and schools. However, there are children and adolescents who live outside of their families of origin in various forms of residential accommodation together with other young people and staff. It can be assumed that food practices and eating habits are central and challenging topics in everyday life in these institutions. Therefore, this paper aimed to provide an overview of the empirical research on food practices in residential care for children and adolescents. We identified 11 studies presented in 19 publications. These studies examined data from 479 children and adolescents, as well as 187 staff members, from 48 residential care units in 8 countries. Due to the interdisciplinary research field, the included studies showed great heterogeneity in the examination of food. In summary, the main foci have been the meaning of food practices in residential care, food practices and forced migration, biopolicy, and nutrition and health. A major topic is the social dimension of food, especially the symbolic meaning in terms of providing care and "making a family". Nutritional or health aspects have been mainly analyzed in terms of eating disorders or providing enough food. Future research on food practices in residential care homes should also pay attention to quantitative designs that include a broader understanding of food, including its social and emotional facets.

Preschool Healthy Food Policy Did Not Increase Percent of Food Wasted: Evidence from the Carolinas

This research evaluates the effects of a South Carolina (SC) policy, which changed the nutrition standards for foods served in early care and education (ECE) settings, on wasted food. A two-group pre-test/post-test evaluation was performed in ECE centers serving children age 3-5 from households with lower incomes in SC (n = 102 children from 34 centers, intervention) and North Carolina (NC; n = 99 children from 30 centers, comparison). Direct observation was performed to assess the quantity and kcal of food served and quantity and percent of food discarded, by food group and nutrient, enabling assessment of waste in the absence of intervention. Mixed-effects linear models were fit to estimate, by state, differences in change from baseline to post-implementation at the center level. Covariates were selected a priori, including center enrollment, racial composition, director educational attainment, years in operation, for-profit status, and Child and Adult Care Food Program (CACFP) participation. Waste of food was high across states and time points. The policy was not associated with a change in percent of food discarded in SC compared to NC in adjusted analyses.

Participation in the CACFP Ensures Availability but not Intake of Nutritious Foods at Lunch in Preschool Children in Child-Care Centers

BACKGROUND

The US Department of Agriculture Child and Adult Care Food program (CACFP) recently (October 2017) updated requirements for meal reimbursement and best practice recommendations for serving nutritious meals and beverages, and minimum age-specific serving sizes for five food groups. It is not known whether CACFP-funded child-care centers are meeting the updated meal pattern requirements and best practice recommendations, and whether children are meeting nutrition recommendations based on the current 2015-2020 Dietary Guidelines for Americans (DGA).

OBJECTIVE

This study assessed whether the recruited CACFP-funded child-care centers in this study were meeting the updated (2017) CACFP requirements regarding foods served for lunch and whether children attending these child-care centers were meeting age- and sex-specific DGA recommendations regarding foods consumed.

DESIGN

This was a cross-sectional study using the Dietary Observation for Child Care method.  PARTICIPANTS AND SETTINGS: Children aged 3 to 5 years (n=108) from 10 classrooms in three CACFP-funded child-care centers in Lincoln, NE, were recruited by convenience sampling during spring 2018.

MEASURABLE OUTCOMES

Food served and consumed during observed lunches in comparison with updated CACFP requirements and DGA, respectively.

STATISTICAL ANALYSIS

Adjusted mean amounts of foods served from each food group were compared with age specific minimum CACFP serving size requirements. Adjusted mean amounts of foods consumed from each food group were then compared with age- and sex-specific DGA recommendations.

RESULTS

The recruited child-care centers were meeting the updated CACFP requirements regarding foods served but showed limited adherence to the best practice recommendations during the observed lunches. However, the overall mean intake for grains, fruits, and vegetables was significantly lower (P<0.01) than DGA recommendations. In addition, approximately 25% of the children did not consume any vegetables during their meal.      CONCLUSIONS: Although child-care centers were meeting the updated CACFP requirements by serving the recommended amounts of foods, children were not meeting DGA-recommended intakes. Future studies are needed to explore ways to improve adherence to best practice recommendations to improve children's consumption of healthy foods in child-care centers.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Testing the effects of interventions to increase consumption of fruit and vegetables, including those focused on specific child-feeding strategies or broader multicomponent interventions targeting the home or childcare environment is required to assess the potential to reduce this disease burden.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 January 2020. We searched Proquest Dissertations and Theses in November 2019. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included trials to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 80 trials with 218 trial arms and 12,965 participants. Fifty trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fifteen trials examined the impact of parent nutrition education only in increasing child fruit and vegetable intake. Fourteen trials examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake. One trial examined the impact of a child-focused mindfulness intervention in increasing vegetable intake. We judged 23 of the 80 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is low-quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption, equivalent to an increase of 5.30 grams as-desired consumption of vegetables (SMD 0.50, 95% CI 0.29 to 0.71; 19 trials, 2140 participants; mean post-intervention follow-up = 8.3 weeks). Multicomponent interventions versus no intervention has a small effect on child consumption of fruit and vegetables (SMD 0.32, 95% CI 0.09 to 0.55; 9 trials, 2961 participants; moderate-quality evidence; mean post-intervention follow-up = 5.4 weeks), equivalent to an increase of 0.34 cups of fruit and vegetables a day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.13, 95% CI -0.02 to 0.28; 11 trials, 3050 participants; very low-quality evidence; mean post-intervention follow-up = 13.2 weeks). We were unable to pool child nutrition education interventions in meta-analysis; both trials reported a positive intervention effect on child consumption of fruit and vegetables (low-quality evidence). Very few trials reported long-term effectiveness (6 trials), cost effectiveness (1 trial) or unintended adverse consequences of interventions (2 trials), limiting our ability to assess these outcomes. Trials reported receiving governmental or charitable funds, except for four trials reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 80 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited in terms of quality of evidence and magnitude of effect. Of the types of interventions identified, there was moderate-quality evidence that multicomponent interventions probably lead to, and low-quality evidence that child-feeding practice may lead to, only small increases in fruit and vegetable consumption in children aged five years and under. It is uncertain whether parent nutrition education or child nutrition education interventions alone are effective in increasing fruit and vegetable consumption in children aged five years and under. Our confidence in effect estimates for all intervention approaches, with the exception of multicomponent interventions, is limited on the basis of the very low to low-quality evidence. Long-term follow-up of at least 12 months is required and future research should adopt more rigorous methods to advance the field. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Knowledge, Attitudes and Practices of Australian Trainee Childcare Educators Regarding Their Role in the Feeding Behaviours of Young Children

Background: Early childhood (2-5 years) is acknowledged as a critical time for the establishment of healthy behaviours. The increasing number of children and amount of time spent in childcare provides strong rationale to explore the important role that childcare services and childcare educators play in influencing healthy eating behaviours of young children in their care. Methods: This study used a qualitative exploratory approach to describe the knowledge, attitudes and practices of Australian childcare trainee educators' regarding their role in the feeding of young children. Results: All participants agreed that feeding of young children was an important part of their role, but described challenges to the promotion of healthy eating and the adoption of responsive child feeding practices. These included personal beliefs and experiences with food, the bi-directional nature of child feeding, conflicting parental requests and/or unsupportive centre-based policies and procedures. Conclusion: Training about responsive child feeding practices within the childcare sector should include all childcare staff; aim to enhance relational efficacy and communication skills with parents; and empower childcare staff to lead organisational change. To support this, childcare centres need to provide coherent centre-based healthy eating policies inclusive of healthy food provision and desirable feeding practices.

The Healthy Cooking Index: Nutrition Optimizing Home Food Preparation Practices across Multiple Data Collection Methods

BACKGROUND

Food preparation interventions are an increasingly popular target for hands-on nutrition education for adults, children, and families, but assessment tools are lacking. Objective data on home cooking practices, and how they are interpreted through different data collection methods, are needed.

OBJECTIVE

The goal of this study was to explore the utility of the Healthy Cooking Index in coding multiple types of home food preparation data and elucidating healthy cooking behavior patterns.

DESIGN

Parent-child dyads were recruited between October 2017 and June 2018 in Houston and Austin, Texas for this observational study. Food preparation events were observed and video recorded. Participants also wore a body camera (eButton) and completed a questionnaire during the same event.

PARTICIPANTS/SETTING

Parents with a school-aged child were recruited as dyads (n=40). Data collection procedures took place in participant homes during evening meal preparation events.

MAIN OUTCOME MEASURES

Food preparation data were collected from parents through direct observation during preparation as well as eButton and paper questionnaires completed immediately after the event.

STATISTICAL ANALYSES PERFORMED

All data sets were analyzed using the Healthy Cooking Index coding system and compared for concordance. A paired sample t test was used to examine significant differences between the scores. Cronbach's α and principal components analysis were conducted on the observed Healthy Cooking Index items to examine patterns of cooking practices.

RESULTS

Two main components of cooking practices emerged from the principal components analysis: one focused on meat products and another on health and taste enhancing practices. The eButton was more accurate in collecting Healthy Cooking Index practices than the self-report questionnaire. Significant differences were found between participant reported and observed summative Healthy Cooking Index scores (P<0.001), with no significant differences between scores computed from eButton images and observations (P=0.187).

CONCLUSIONS

This is the first study to examine nutrition optimizing home cooking practices by observational, wearable camera and self-report data collection methods. By strengthening cooking behavior assessment tools, future research will be able to elucidate the transmission of cooking education through interventions and the relationships between cooking practices, disease prevention, and health.

The Impact of Responsive Feeding Practice Training on Teacher Feeding Behaviors in Tribal Early Care and Education: The Food Resource Equity and Sustainability for Health (FRESH) Study

BACKGROUND

Establishing healthy eating habits early affects lifelong dietary intake, which has implications for many health outcomes. With children spending time in early care and education (ECE) programs, teachers establish the daytime meal environment through their feeding practices.

OBJECTIVE

We aimed to determine the effect of a teacher-focused intervention to increase responsive feeding practices in 2 interventions, 1 focused exclusively on the teacher's feeding practices and the other focused on both the teacher's feeding practices and a nutrition classroom curriculum, in ECE teachers in a Native American (NA) community in Oklahoma.

METHODS

Nine tribally affiliated ECE programs were randomly assigned to 1 of 2 interventions: 1) a 1.5-h teacher-focused responsive feeding practice training (TEACHER; n = 4) and 2) TEACHER plus an additional 3-h training to implement a 15-wk classroom nutrition curriculum (TEACHER + CLASS; n = 5). Feeding practice observations were conducted during lunch at 1 table in 1 classroom for 2- to 5-y-olds at each program before and 1 mo after the intervention. The Mealtime Observation in Child Care (MOCC) organizes teacher behaviors into 8 subsections. Descriptive statistics and the Shapiro-Wilk test for normality were calculated. Paired t tests were calculated to determine change in each group.

RESULTS

A mean ± SD of 5.2 ± 2.0 (total n = 47) children and 1.7 ± 0.5 (total n = 14) teachers/center were observed at baseline, and 5.6 ± 1.7 (total n = 50) children and 1.7 ± 0.7 teachers (total n = 14) were observed/center postintervention. Total MOCC scores (max possible = 10) improved for TEACHER (6.1 ± 0.9 compared with 7.5 ± 0.3, t = 4.12, P = 0.026) but not for TEACHER + CLASS (6.5 ± 0.8 compared with 6.4 ± 1.0, t = -0.11, P = 0.915). No other changes were observed.

CONCLUSIONS

Teacher intervention-only programs demonstrated improvements in responsive feeding practices, whereas the programs receiving teacher and classroom training did not. Greater burden likely decreased capacity to make changes in multiple domains. We demonstrated the ability to implement interventions in NA ECE. Further research with larger communities is necessary. This trial was registered at clinicaltrials.gov as NCT03251950.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Interventions to increase consumption of fruit and vegetables, such as those focused on specific child-feeding strategies and parent nutrition education interventions in early childhood may therefore be an effective strategy in reducing this disease burden.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 August 2019. We searched Proquest Dissertations and Theses in May 2019. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included trials to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 78 trials with 214 trial arms and 13,746 participants. Forty-eight trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fifteen trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Fourteen trials examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake. One trial examined the impact of a child-focused mindfulness intervention in increasing vegetable intake. We judged 20 of the 78 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is very low-quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption equivalent to an increase of 4.45 g as-desired consumption of vegetables (SMD 0.42, 95% CI 0.23 to 0.60; 18 trials, 2004 participants; mean post-intervention follow-up = 8.2 weeks). Multicomponent interventions versus no intervention has a small effect on child consumption of fruit and vegetables (SMD 0.34, 95% CI 0.10 to 0.57; 9 trials, 3022 participants; moderate-quality evidence; mean post-intervention follow-up = 5.4 weeks), equivalent to an increase of 0.36 cups of fruit and vegetables per day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.12, 95% CI -0.03 to 0.28; 11 trials, 3078 participants; very low-quality evidence; mean post-intervention follow-up = 13.2 weeks). We were unable to pool child nutrition education interventions in meta-analysis; both trials reported a positive intervention effect on child consumption of fruit and vegetables (low-quality evidence). Very few trials reported long-term effectiveness (6 trials), cost effectiveness (1 trial) and unintended adverse consequences of interventions (2 trials), limiting their assessment. Trials reported receiving governmental or charitable funds, except for four trials reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 78 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited. There was very low-quality evidence that child-feeding practice may lead to, and moderate-quality evidence that multicomponent interventions probably lead to small increases in fruit and vegetable consumption in children aged five years and younger. It is uncertain whether parent nutrition education interventions are effective in increasing fruit and vegetable consumption in children aged five years and younger. Given that the quality of the evidence is very low or low, future research will likely change estimates and conclusions. Long-term follow-up of at least 12 months is required and future research should adopt more rigorous methods to advance the field. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Nutrition-Related Practices of Family Child Care Providers and Differences by Ethnicity

BACKGROUND

Child care settings play an important role in shaping children's eating behaviors; yet few studies have included family child care homes (FCCHs). We examined provider-reported nutrition-related practices in FCCHs and observed adherence to nutrition guidelines from the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC), exploring differences by provider ethnicity.

METHODS

We assessed baseline data from a cluster-randomized trial, including surveys with FCCH providers and observational data collected at the FCCH. We examined provider-reported nutrition-related practices and if providers met NAP SACC guidelines using observational data. Differences by ethnicity were assessed using chi-square and multivariate log-linear analysis adjusting for education.

RESULTS

Providers completed a telephone survey (n = 166, 100% female and 72% Hispanic) and participated in 2 full-day observations (n = 119). Many providers reported engaging in positive nutrition-related practices. Significant differences by ethnicity included the following: Hispanic providers less likely to report feeding practices that were responsive to children's self-regulation, but also less likely to report eating and drinking unhealthy foods/beverages in front of children and having screens on during meals and more likely to report seeking nutrition trainings. Using observational data, only 10 of 26 NAP SACC practices were met by >60% of providers. Few ethnic differences in meeting guidelines were found (7 of 26 practices).

CONCLUSIONS

While providers engage in some positive nutrition practices, improvement is needed to ensure that all providers actually meet evidence-based guidelines. Ethnic differences in certain practices underscore the need for culturally relevant trainings.

TRIAL REGISTRATION NUMBER

NCT02452645.

The Quality of Nutrition and Physical Activity Environments of Family Child-Care Homes in a State in the Southern United States

BACKGROUND

Family child-care homes (FCCHs) are an important provider of nonparental child care for low-income families. Little is known about the quality of nutrition and physical activity environments of FCCHs in the southern United States, where child obesity and child poverty levels are high.

OBJECTIVES

To assess the quality of the nutrition and physical activity environments of a sample of FCCHs in Mississippi and examine the differences by urban vs rural location.

DESIGN

Cross-sectional study.

PARTICIPANTS/SETTING

Data were from a random sample of 134 FCCHs that enroll children aged 3 to 5 years. The sample was stratified by urban vs rural location and participation in the Child and Adult Care Food Program. Providers completed a modified version of the Environment and Policy Assessment and Observation-Self Report tool by mail and reported on provisions, practices, policies, and the general FCCH nutrition and physical activity environment.

MAIN OUTCOME MEASURES

A nutrition environment score (range=0 to18), physical activity environment score (range=0 to 24), and a combined nutrition and physical activity environment score (range=0 to 42) were calculated from Environment and Policy Assessment and Observation-Self Report tool data.

STATISTICAL ANALYSES PERFORMED

Descriptive statistics and t tests were computed, with statistical significance set at P≤0.05.

RESULTS

Average scores for the nutrition, physical activity, and combined nutrition and physical activity environment were 9.4, 11.1, and 20.5, respectively. The average nutrition environment score (9.6 vs 9.2; P=0.39) and physical activity environment score (11.3 vs 11.0; P=0.62) did not differ between urban and rural homes. The combined nutrition and physical activity scores (20.8 vs 20.2; P=0.50) also did not differ between urban and rural homes.

CONCLUSIONS

Findings highlight the need to improve the nutrition and physical activity environments of FCCHs, regardless of geographic location. Further research is needed to understand barriers to providing higher-quality nutrition and physical activity environments.

Modifying the Environment and Policy Assessment and Observation (EPAO) to better capture feeding practices of family childcare home providers

OBJECTIVE

To describe the modification and validation of an existing instrument, the Environment and Policy Assessment and Observation (EPAO), to better capture provider feeding practices.

DESIGN

Modifications to the EPAO were made, validity assessed through expert review, pilot tested and then used to collect follow-up data during a two-day home visit from an ongoing cluster-randomized trial. Exploratory factor analysis investigated the underlying factor structure of the feeding practices. To test predictive validity of the factors, multilevel mixed models examined associations between factors and child's diet quality as captured by the Healthy Eating Index-2010 (HEI-2010) score (measured via the Dietary Observation in Childcare Protocol).

SETTING

Family childcare homes (FCCH) in Rhode Island and North Carolina, USA.ParticipantsThe modified EPAO was pilot tested with fifty-three FCCH and then used to collect data in 133 FCCH.

RESULTS

The final three-factor solution ('coercive control and indulgent feeding practices', 'autonomy support practices', 'negative role modelling') captured 43 % of total variance. In multilevel mixed models adjusted for covariates, 'autonomy support practices' was positively associated with children's diet quality. A 1-unit increase in the use of 'autonomy support practices' was associated with a 9·4-unit increase in child HEI-2010 score (P=0·001).

CONCLUSIONS

Similar to the parenting literature, constructs which describe coercive controlling practices and those which describe autonomy-supportive practices emerged. Given that diets of pre-schoolers in the USA remain suboptimal, teaching childcare providers about supportive feeding practices may help improve children's diet quality.

Prospective associations between parental feeding practices and children's oral processing behaviours

Previous research demonstrated that faster eating rates are linked with increased intake of energy during a meal. Here, we examined whether within-meal parental feeding practices show cross-sectional and prospective associations with children's oral processing behaviours and whether the previously demonstrated association between faster eating rates and higher energy intakes varies by parental feeding practices. A subset (n = 155) of children and their mothers from the Growing Up in Singapore Towards healthy Outcomes cohort participated in an ad libitum meal at age 4.5 years. Children's oral processing behaviours (eating rate, bite size, chews per gram, oral exposure time, and meal duration) and parental feeding practices (autonomy-supporting and coercive prompts, restrictions, hurrying, and slowing) were recorded during the meal. Subsequently, 94 of the children participated in a follow-up meal without their mothers at age 6 years. Parental feeding practices were not consistently associated with child oral processing behaviours overall. However, exploratory post hoc analyses revealed some sex differences. The mothers of girls with faster eating rates, larger bite sizes, and fewer chews were more likely to use hurrying, slowing, and restrictions, but similar associations were not observed among boys. Children who had the most problematic eating style and were eating fast and for long experienced more restrictions, instructions to slow down, and prompts. Faster eating rates were linked with the highest energy intakes if children were additionally prompted to eat. Prospective analyses showed that children who were more often prompted using coercive techniques and less frequently hurried at age 4.5 years had faster eating rates at 6 years and a larger increase in eating rates between ages 4.5 and 6 years but did not consume more energy. Although the direction of these associations cannot be assumed, these exploratory analyses suggest sex differences in the associations between feeding practices and oral processing behaviours and highlight the potential role of parents in the development of children's oral processing behaviours.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Interventions to increase consumption of fruit and vegetables, such as those focused on specific child-feeding strategies and parent nutrition education interventions in early childhood may therefore be an effective strategy in reducing this disease burden.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 January 2018. We searched Proquest Dissertations and Theses in November 2017. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included studies to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included studies; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 63 trials with 178 trial arms and 11,698 participants. Thirty-nine trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fourteen trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Nine studies examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. One study examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake.We judged 14 of the 63 included trials as free from high risks of bias across all domains; performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining studies.There is very low quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption equivalent to an increase of 3.50 g as-desired consumption of vegetables (SMD 0.33, 95% CI 0.13 to 0.54; participants = 1741; studies = 13). Multicomponent interventions versus no intervention may have a very small effect on child consumption of fruit and vegetables (SMD 0.35, 95% CI 0.04 to 0.66; participants = 2009; studies = 5; low-quality evidence), equivalent to an increase of 0.37 cups of fruit and vegetables per day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.12, 95% CI -0.03 to 0.28; participants = 3078; studies = 11; very low-quality evidence).Insufficient data were available to assess long-term effectiveness, cost effectiveness and unintended adverse consequences of interventions. Studies reported receiving governmental or charitable funds, except for four studies reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 63 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited. There was very low- and low-quality evidence respectively that child-feeding practice and multicomponent interventions may lead to very small increases in fruit and vegetable consumption in children aged five years and younger. It is uncertain whether parent nutrition education interventions are effective in increasing fruit and vegetable consumption in children aged five years and younger. Given that the quality of the evidence is very low or low, future research will likely change estimates and conclusions. Long-term follow-up is required and future research should adopt more rigorous methods to advance the field.This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Nutrition Knowledge, Attitudes, and Fruit and Vegetable Intake as Predictors of Head Start Teachers' Classroom Mealtime Behaviors

OBJECTIVE

To examine the association between nutrition knowledge, attitudes, and fruit/vegetable intake among Head Start teachers and their classroom mealtime behaviors (self-reported and observed).

DESIGN

Cross-sectional design using observation and survey.

SETTING

Sixteen Head Start centers across Rhode Island between September, 2014 and May, 2015.

PARTICIPANTS

Teachers were e-mailed about the study by directors and were recruited during on-site visits. A total of 85 participants enrolled through phone/e-mail (19%) or in person (81%).

MAIN OUTCOME MEASURES

Independent variables were nutrition knowledge, attitudes, and fruit/vegetable intake. The dependent variable was classroom mealtime behaviors (self-reported and observed).

ANALYSIS

Regression analyses conducted on teacher mealtime behavior were examined separately for observation and self-report, with knowledge, attitudes, and fruit and vegetable intake as independent variables entered into the models, controlling for covariates.

RESULTS

Nutrition attitudes were positively associated with teacher self-reported classroom mealtime behavior total score. Neither teacher nutrition knowledge nor fruit/vegetable intake was associated with observed or self-reported classroom mealtime behavior total scores.

CONCLUSION AND IMPLICATIONS

There was limited support for associations among teacher knowledge, attitudes, and fruit/vegetable intake, and teacher classroom mealtime behavior. Findings showed that teacher mealtime behavior was significantly associated with teacher experience.

The family child care home environment and children's diet quality

BACKGROUND

Developing healthy eating behaviors and food preferences in early childhood may help establish future healthy diets. Large numbers of children spend time in child care, but little research has assessed the nutritional quality of meals and snacks in family child care homes. Therefore, it is important to assess foods and beverages provided, policies related to nutrition and feeding children, and interactions between providers and children during mealtimes. We examined associations between the nutrition environments of family child care homes and children's diet quality.

METHODS

We assessed the nutrition environments of 166 family child care homes using the Environment and Policy Assessment and Observation (EPAO) (scores range: 0-21). We also recorded foods and beverages consumed by 496 children in care and calculated healthy eating index (HEI) (scores range: 0-100). We used a mixed effects linear regression model to examine the association between the EPAO nutrition environment (and EPAO sub-scales) and child HEI, controlling for potential confounders.

RESULTS

Family child care homes had a mean (standard deviation, SD) of 7.2 (3.6) children in care, 74.1% of providers were black or African American, and children had a mean (SD) age of 35.7 (11.4) months. In adjusted multivariable models, higher EPAO nutrition score was associated with increased child HEI score (1.16; 95% CI: 0.34, 1.98; p = 0.006). Higher scores on EPAO sub-scales for foods provided (8.98; 95% CI: 3.94, 14.01; p = 0.0006), nutrition education (5.37; 95% CI: 0.80, 9.94; p = 0.02), and nutrition policy (2.36; 95% CI: 0.23, 4.49; p = 0.03) were all associated with greater child HEI score.

CONCLUSIONS

Foods and beverages served, in addition to nutrition education and nutrition policies in family child care homes, may be promising intervention targets for improving child diet quality.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future chronic diseases, including cardiovascular disease.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE and Embase to identify eligible trials on 25 September 2017. We searched Proquest Dissertations and Theses and two clinical trial registers in November 2017. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included studies to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included studies; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 55 trials with 154 trial arms and 11,108 participants. Thirty-three trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Thirteen trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Eight studies examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. One study examined the effect of a nutrition intervention delivered to children in increasing child fruit and vegetable intake.We judged 14 of the 55 included trials as free from high risks of bias across all domains; performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining studies.Meta-analysis of trials examining child-feeding practices versus no intervention revealed a positive effect on child vegetable consumption (SMD 0.38, 95% confidence interval (CI) 0.15 to 0.61; n = 1509; 11 studies; very low-quality evidence), equivalent to a mean difference of 4.03 g of vegetables. There were no short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.11, 95% CI -0.05 to 0.28; n = 3023; 10 studies; very low-quality evidence) or multicomponent interventions versus no intervention (SMD 0.28, 95% CI -0.06 to 0.63; n = 1861; 4 studies; very low-quality evidence).Insufficient data were available to assess long-term effectiveness, cost effectiveness and unintended adverse consequences of interventions. Studies reported receiving governmental or charitable funds, except for three studies reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 55 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains sparse. There was very low-quality evidence that child-feeding practice interventions are effective in increasing vegetable consumption in children aged five years and younger, however the effect size was very small and long-term follow-up is required. There was very low-quality evidence that parent nutrition education and multicomponent interventions are not effective in increasing fruit and vegetable consumption in children aged five years and younger. All findings should be considered with caution, given most included trials could not be combined in meta-analyses. Given the very low-quality evidence, future research will very likely change estimates and conclusions. Such research should adopt more rigorous methods to advance the field.This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Examining the Obesogenic Attributes of the Family Child Care Home Environment: A Literature Review

Childhood obesity is a major public health concern in the US. More than a third of young children 2-5 years old are placed in nonrelative child care for the majority of the day, making the child care setting an important venue to spearhead obesity prevention. Much of the obesity research in child care has focused on center-based facilities, with emerging research on Family Child Care Homes (FCCHs)-child care operated in a home setting outside the child's home. The purpose of this review was to assess the obesogenic attributes of the FCCH environment. A search of the PubMed, Embase, CINHAL, and PsycINFO electronic databases identified 3,281 citations; 35 eligible for full-text review, and 18 articles from 17 studies in the analysis. This review found a lack of comprehensive written nutrition and physical activity policies within FCCHs, lack of FCCH providers trained in nutrition and physical activity best practices, lack of adequate equipment and space for indoor and outdoor playtime activities in FCCHs, inaccurate nutrition-related beliefs and perceptions among FCCH providers, poor nutrition-related communication with families, and poor feeding practices. Future research focusing on interventions aimed at addressing these problem areas can contribute to obesity prevention.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future chronic diseases, including cardiovascular disease.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE, Embase Classic and Embase to identify eligible trials on 30 September 2016. We searched CINAHL and PsycINFO in July 2016, Proquest Dissertations and Theses in November 2016 and three clinical trial registers in November 2016 and June 2017. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included studies to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included studies; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures.We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 50 trials with 137 trial arms and 10,267 participants. Thirty trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Eleven trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Eight studies examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. One study examined the effect of a nutrition intervention delivered to children in increasing child fruit and vegetable intake.Thirteen of the 50 included trials were judged as free from high risks of bias across all domains; performance, detection and attrition bias were the most common domains judged at high risk of bias of remaining studies.Meta-analysis of trials examining child-feeding practices versus no intervention revealed a positive effect on child vegetable consumption (SMD 0.38, 95% CI 0.15 to 0.61; n = 1509; 11 studies; very low-quality evidence), equivalent to a mean difference of 4.03 grams of vegetables. There were no short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.11, 95% CI -0.05 to 0.28; n = 3023; 10 studies; very low-quality evidence) or multicomponent interventions versus no intervention (SMD 0.28, 95% CI -0.06 to 0.63; n = 1861; 4 studies; very low-quality evidence).Insufficient data were available to assess long-term effectiveness, cost effectiveness and unintended adverse consequences of interventions.Studies reported receiving governmental or charitable funds, except for two studies reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 50 eligible trials of various intervention approaches, the evidence for how to increase fruit and vegetable consumption of children remains sparse. There was very low-quality evidence child-feeding practice interventions are effective in increasing vegetable consumption of children aged five years and younger, however the effect size was very small and long-term follow-up is required. There was very low-quality evidence that parent nutrition education and multicomponent interventions are not effective in increasing fruit and vegetable consumption of children aged five years and younger. All findings should be considered with caution, given most included trials could not be combined in meta-analyses. Given the very low-quality evidence, future research will very likely change estimates and conclusions. Such research should adopt more rigorous methods to advance the field.This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Self-reported and observed feeding practices of Rhode Island Head Start teachers: Knowing what not to do

PURPOSE

Through their feeding practices, adult caregivers play an important role in shaping children's eating behaviors. However, the feeding practices of child care teachers have received little attention. The purpose of this study was to compare child care teachers' self-reported feeding practices and observed feeding practices during a preschool meal.

METHODS

Rhode Island Head Start teachers (n = 85) were observed during breakfast and lunch where feeding practices were coded using a tool adapted from the Environmental Policy Assessment and Observation (EPAO) tool. Teachers completed a questionnaire adapted from the EPAO Self-Report to capture self-reported feeding practices. Agreement between reported and observed was compared by percent agreement.

RESULTS

Teachers were predominantly White (89%) and female (98%). There was a higher level of agreement among self-reported and observed controlling feeding practices (78.8-97.6% agreement) compared to healthful feeding practices (11.8-20.0% agreement).

CONCLUSIONS

Although self-report measures are typically used to capture feeding practices, there are inconsistencies between self-report and observation measures. The inconsistencies found among healthful self-reported and observed feeding practices have implications for future research protocols, measurement refinement, and training of child care teachers.

Providers perspectives on self-regulation impact their use of responsive feeding practices in child care

Supporting children's self-regulation in eating through caregivers' practice of responsive feeding is paramount to obesity prevention, and while much attention has been given to supporting children's self-regulation in eating through parents' responsive feeding practices in the home setting, little attention has been given to this issue in childcare settings. This qualitative study examines childcare providers' perspectives on using responsive feeding practices with young children (2-5years). Individual semi-structured interviews were conducted with providers until saturation was reached. Data was analyzed using thematic analysis. The final sample included 18 providers who were employed full-time in Head Start or state-licensed center-based childcare programs, cared for children (2-5y), and were directly responsible for serving meals and snacks. Providers were primarily (67%) employed in childcare programs that served children from low-income families and received reimbursement for meals and snacks from the US Department of Agriculture's Child and Adult Care Food Program. Three factors emerged that shaped childcare providers' experiences using responsive feeding practices: the providers' perspectives about whether or not young children can self-regulate food intake, their understanding of Child and Adult Care Food Program (CACFP) portion size regulations, and the availability of food at the center where they worked. Future research should examine how childcare providers' understanding of children's ability to self-regulate their food intake, the appropriate use of the CACFP regulations in relationship to serving sizes, and having food available to offer seconds promotes providers' use of responsive feeding practices in center-based childcare programs and children's dietary behaviors.

Bi-directional associations between child fussy eating and parents' pressure to eat: Who influences whom?

Background

Fussy eating is common in young children, often raising concerns among parents. The use of pressuring feeding practices may provoke or worsen child fussiness, but these practices could equally be a parent’s response to child fussy eating.

Objective

In longitudinal analyses, we assessed directionality in the relation between fussy eating and parent’s pressure to eat across childhood.

Methods

Study participants were 4845 mother-child dyads from the population-based Generation R cohort in the Netherlands. The Child Behavior Checklist was used to assess fussy eating (2 items) at child ages 1½, 3 and 6 years. Parents’ pressure to eat was assessed with the Child Feeding Questionnaire (4 items) when children were 4 years old. All scale scores were standardized.

Results

Linear regression analyses indicated that preschoolers’ fussy eating prospectively predicted higher levels of parents’ pressure to eat at child age 4 years, independently of confounders (adjusted B=0.24, 95% CI: 0.21, 0.27). Pressure to eat at 4 years also predicted more fussiness in children at age 6 years, independently of confounders and of fussy eating at baseline (adjusted B=0.14, 95% CI: 0.11, 0.17). Path analyses indicated that the relation from fussy eating at 3 years to parenting one year later was stronger than from pressure at 4 years to fussy eating two years later (p<0.001).

Conclusions

Our findings suggest bi-directional associations with parental pressuring feeding strategies being developed in response to children’s food avoidant behaviors, but also seemingly having a counterproductive effect on fussiness. Thus, the use of pressure to eat should be reconsidered, while providing parents alternative techniques to deal with their child’s fussy eating.