Application and validation of the Feeding Infants: Behaviour and Facial Expression Coding System (FIBFECS) to assess liking and wanting in infants at the time of complementary feeding

Appetite and childhood malnutrition: A narrative review identifying evidence gaps between clinical practice and research

Severe Acute Malnutrition (SAM) is a critical global health issue, contributing to approximately one-half of all child mortality worldwide. SAM management guidelines recommend the use of appetite assessment determined by an "appetite test" to distinguish between complicated and uncomplicated SAM, subsequently guiding clinical decisions regarding outpatient versus inpatient care and discharge from hospital. Despite the widespread utilization of this recommendation, its validity lacks substantial evidence within the existing literature. Hence, the aims of this narrative review were to provide an overview of the SAM diagnostic and management guideline recommendations concerning the use of appetite assessment; to review the existing knowledge base supporting this clinical practice. The review identified gaps between the clinical use of appetite assessment in SAM management and the available supporting scientific evidence. Additionally, both the opportunities and challenges associated with appetite assessment methods used in clinical practice were highlighted and discussed in relation to existing literature. Further studies with more rigorous methods are needed to bridge these gaps and formulate evidence-based clinical practice. There is also a need to adapt and validate the existing appetite assessment tools to ensure they are tailored to the specific population, setting, and primary purpose of assessing appetite in children who have already developed SAM.

Development and validation of the baby eating behaviour coding system (BEBECS) to assess eating behaviour during complementary feeding

Eating behaviour in children is a matter of study for which diverse tools have been designed. Coding systems for videotaped meals allow the extraction of detailed in vivo information; however, there is no tool available for infants following a Baby-Led Weaning (BLW) method. This study aimed to create and validate a new tool to assess eating behaviour in infants during weaning, applicable regardless of the complementary feeding method. The Baby Eating Behaviour Coding System (BEBECS) was developed comprising time variables, behaviours, feeder-led actions, and other meal-related variables. Sixty videos of infants aged 6-18 months following spoon-feeding (SF) or BLW methods were coded by two trained coders. These scores were analysed together with intake and maternal ratings of liking and calmness. Additionally, combined analysis and internal comparison assessed the possible differences in BEBECS variables between SF and BLW. Inter-rater and test-retest reliability had good to excellent agreement: Cohen's Kappa >0.75, Lin's CCC >0.70, and Intraclass Correlation Coefficient >0.75, for almost all variables. Infants' liking and intake of the offered food correlated positively with meal duration and total count of mouth approaches but negatively with having leftovers and time between mouth approaches. Infants' calmness and tiredness were negatively correlated. More food than initially offered was available during the meal in BLW but not in SF. There was a tendency towards more autonomous behaviour in BLW infants regarding changes observed in the time the food was in the mouth at each stage (6, 12, and 18 months). In conclusion, BEBECS has the potential to be a valid tool for application in the research of infant eating behaviour during weaning by trained coders.

Conceptual Considerations and Methodological Challenges to Measuring Food Acceptance During Infancy

PURPOSE OF REVIEW

The purpose of this review is to (1) present a conceptual definition of infant food acceptance, (2) explore methodological challenges to measuring different components of food acceptance, and (3) provide recommendations for future research on food acceptance during infancy.

RECENT FINDINGS

Infant food acceptance includes separate but overlapping components: wanting, liking, and consumption. Recent evidence suggests that although these components are often correlated, there is variability in the sensitivity of these measures to detect differences in infants' responses to target foods. To date, consumption and caregiver perceptions of liking have been the primary outcome measures of interest in studies of infant food acceptance. More diverse and precise measures across the three components of infant food acceptance are needed to address a wider scope of research questions, which would in turn strengthen the interpretability and translational potential of research in this area.

"The Kale Is Green" and Other Things Caregivers Say when Feeding Infants and Toddlers Are Associated with Child Rate of Acceptance

BACKGROUND

Responsive feeding is important for helping children to develop healthy eating behaviors. Verbal feeding interactions between caregivers and children may reflect caregiver's responsiveness and contribute to children's developing lexical networks related to food and eating.

OBJECTIVES

This project aimed to: 1) characterize what caregivers say to infants and toddlers during a single feeding session and 2) test the associations between caregiver's verbal prompts and food acceptance by children.

METHODS

Filmed interactions of caregivers and their infants (N = 46 infants aged 6-11 mo) and toddlers (N = 60 toddlers aged 12-24 mo) were coded and analyzed to explore the following: 1) what caregivers said during a single feeding session and 2) whether caregiver's verbalizations were associated with child food acceptance. Caregiver verbal prompts were coded during each food offer and summed across the feeding session; prompts were categorized as supportive, engaging, and unsupportive. Outcomes included accepted tastes, rejected tastes, and rate of acceptance. Mann-Whitney's U tests and Spearman's correlations tested bivariate associations. Multilevel ordered logistic regression tested associations between verbal prompt categories and the rate of acceptance across offers.

RESULTS

Verbal prompts were largely supportive (41%) and engaging (46%), and caregivers of toddlers used significantly more verbal prompts than caregivers of infants (mean ± SD: 34.5 ± 16.9 compared with 25.2 ± 11.6; P = 0.006). Among toddlers, more engaging and unsupportive prompts were associated with a lower rate of acceptance (ρ = -0.30, P = 0.02; ρ = -0.37, P = 0.004). For all children, multilevel analyses revealed that more unsupportive verbal prompts were associated with a lower rate of acceptance (b = -1.52; SE = 0.62; P = 0.01) and individual caregiver use of more engaging and unsupportive prompts than usual was associated with a lower rate of acceptance (b = -0.33; SE = 0.08; P < 0.001: b = -0.58; SE = 0.11; P < 0.001).

CONCLUSIONS

These findings suggest that caregivers may strive for a supportive and engaging emotional setting during feeding, although verbalization category may change as children exhibit more rejection. Furthermore, what caregivers say may change as children develop more advanced language capabilities.

From food preference development to responsive feeding - Selective studies to commemorate the life and work of Dr Leann Birch

Dr Leann Birch was a pioneer in conducting research on infant and child eating behaviour. At the beginning of her research career, Leann recognised a significant gap in the developmental psychology literature, namely that few studies had been conducted to understand infant eating and feeding behaviours. This seems an unusual omission given that food intake is essential and that developmental milestones from milk to solids, and from being fed to becoming an autonomous eater, are obvious to most caregivers. Leann paved the way for interdisciplinary research from psychology, paediatrics and public health to explore and apply this knowledge to infant and child appetite, eating behaviour, dietary patterns, food preferences, and obesity risk. Early studies in her laboratory demonstrated that children form food preferences through experience and socialisation. Experiments published in 1979 tested the role of familiarisation through repeat exposure, and the impact of instrumental and social learning on the acquisition of food preferences. In 1984, a presentation given to the British Feeding and Drinking Group (BFDG) in Brighton set out three organising principles for understanding how children acquire food preferences: genetically pre-programmed behavioural propensities; social constraints on experience with food; and social transmission resulting from direct social interaction. Building on these three organising principles, research on child eating behaviour has flourished, including the intersection between individual differences, food experience and environmental influences on children's food preferences, energy regulation, and weight outcomes. In this review, the initial groundwork set out by Leann Birch on food preference development in children is considered followed by a discussion of how this has since inspired an interdisciplinary, international and expanding field of research on children's food intake, appetite and body weight regulation.

Development of a live coding method to assess infant/toddler food acceptance

Validated measures predicting infant consumption of nutrient supplements or fortified foods are essential for the success of nutritional interventions to improve undernutrition. Behavioural coding of food acceptance is one promising approach, though the required time and resources are limiting. The overarching goal of the present study was to adapt a video coding (VC) protocol for use as a live coding (LC) method to assess infant food acceptance in naturalistic settings. Infants (n = 59; ages 7–24 months) were fed a small‐quantity lipid‐based nutrient supplement (SQ‐LNS) mixed with a familiar food by caregivers in the State of Morelos, Mexico. Trained coders used a VC scheme to rate infant acceptance of each spoon offer using a 4‐point scale. The VC scheme was subsequently adapted for use as an LC method to be used in participant homes and a video live coding (VLC) method to monitor reliability. Reliability and validity of the LC method were tested in a subsample of dyads (n = 20). Intraclass correlation coefficients (ICCs) indicated that the inter‐rater reliability between coders using the LC method was moderate or good when compared to VC methods (ICCs = 0.75 and 0.87). Live coded acceptance scores were also moderately associated with consumption of the SQ‐LNS (ρ = 0.50, p = 0.03). The LC scheme demonstrated initial reliability and validity as an assessment of infant food acceptance. Since VC is both resource and time‐intensive, the LC scheme may be useful for assessing infant food acceptance in resource‐limited settings.

Current measures to assess infant food acceptance in nutritional interventions are limited.

This study presents a live coding scheme and protocol that can be used to objectively rate infants’ food acceptance in naturalistic settings.

The coding method demonstrated initial reliability with video coding methods and was associated with infants’ consumption of a target food.

The live coding protocol may be particularly useful for assessing infant food acceptance in resource‐limited settings.

Feasibility of the automatic ingestion monitor (AIM-2) for infant feeding assessment: a pilot study among breast-feeding mothers from Ghana

OBJECTIVE

Passive, wearable sensors can be used to obtain objective information in infant feeding, but their use has not been tested. Our objective was to compare assessment of infant feeding (frequency, duration and cues) by self-report and that of the Automatic Ingestion Monitor-2 (AIM-2).

DESIGN

A cross-sectional pilot study was conducted in Ghana. Mothers wore the AIM-2 on eyeglasses for 1 d during waking hours to assess infant feeding using images automatically captured by the device every 15 s. Feasibility was assessed using compliance with wearing the device. Infant feeding practices collected by the AIM-2 images were annotated by a trained evaluator and compared with maternal self-report via interviewer-administered questionnaire.

SETTING

Rural and urban communities in Ghana.

PARTICIPANTS

Participants were thirty eight (eighteen rural and twenty urban) breast-feeding mothers of infants (child age ≤7 months).

RESULTS

Twenty-five mothers reported exclusive breast-feeding, which was common among those < 30 years of age (n 15, 60 %) and those residing in urban communities (n 14, 70 %). Compliance with wearing the AIM-2 was high (83 % of wake-time), suggesting low user burden. Maternal report differed from the AIM-2 data, such that mothers reported higher mean breast-feeding frequency (eleven v. eight times, P = 0·041) and duration (18·5 v. 10 min, P = 0·007) during waking hours.

CONCLUSION

The AIM-2 was a feasible tool for the assessment of infant feeding among mothers in Ghana as a passive, objective method and identified overestimation of self-reported breast-feeding frequency and duration. Future studies using the AIM-2 are warranted to determine validity on a larger scale.

Analysis of Pungency Sensation Effects from an Oral Processing, Sensorial and Emotions Detection Perspective—Case Study with Grilled Pork Meat

Pungency is an interesting sensory stimulus analyzed from different perspectives, in particular the underpinning mechanisms of its sensation and perception. In this study, grilled pork meat coated with three types of hot sauces were investigated regarding its main food oral processing characteristics and evaluated using time-intensity and temporal dominance of pungency sensations methods analyzing the pungency descriptors and intensities. Besides these methods, facial expressions obtained from video capturing were subject to emotion detection. Mastication parameters showed a slight, but not statistically significant, trend of an increased number of chews and consumption time associated with pungency intensity, while saliva incorporation indicated an increasing trend depending on the pungency intensity, especially after 25 strokes and before swallowing. Both time intensity and temporal dominance of pungency sensations showed that the complexity of understanding these sensations is in relation to intensity and type. Finally, the use of emotion detection software in analyzing the faces of panelists during mastication confirmed the increase in non-neutral emotions associated with the increase in pungency intensity.

Infant and Toddler Responses to Bitter-Tasting Novel Vegetables: Findings from the Good Tastes Study

BACKGROUND

Infants are born with the biological predisposition to reject bitterness. Dark green vegetables contain essential nutrients but also bitter compounds, making them more difficult to like.

OBJECTIVE

The Good Tastes Study was designed to determine whether reducing bitterness by adding small amounts of sugar or salt would alter infant acceptance of kale purées.

METHODS

Caregivers (n = 106, 94% mothers, 82% Non-Hispanic White) and children (53% male, aged 6-24 mo) participated in a videorecorded laboratory visit during which infants were offered 4 versions of puréed kale: plain, 1.2% or 1.8% added sugar, or 0.2% added salt. Caregivers rated their children's liking for each kale version. Videos were coded for the number of tastes accepted and for children's behaviors and acceptance of each kale version. A multilevel ordered logistic model was fit for the number of accepted tastes and caregiver ratings of child liking of kale versions with age, breastfeeding history, order effects, and kale version as predictors.

RESULTS

Infants 6 to <12 mo accepted more tastes (b = 2.911, P < 0.001) and were rated by caregivers as liking the kale more than older toddlers (≥18 mo; b = 1.874, P = 0.014). The plain kale was more likely to be accepted (P < 0.001); also, the first version offered was more likely to be rejected (b = -0.586, P < 0.007). Older infants (≥18 mo) exhibited more avoidant behaviors (b = 1.279, P < 0.001), more playing (b = 2.918, P < 0.001), and more self-feeding (b = 1.786, P = 0.005) than younger infants (6 to <12 mo). Children who were reported to have been breastfed more in the last 7 d were more likely to self-feed (b = 0.246, P < 0.001) and play with food (b = 0.207, P < 0.005).

CONCLUSIONS

Our findings support that there may be a sensitive period, during the early phase of complementary feeding, to improve success of introducing a novel, bitter, more difficult-to-like food. When low levels of sugar or salt were added, no advantage of bitterness reduction was observed. This study has been registered with ClinicalTrials.gov as NCT04549233.

Impact of a "vegetables first" approach to complementary feeding on later intake and liking of vegetables in infants: a study protocol for a randomised controlled trial

BACKGROUND

Vegetables as first complementary foods for infants may programme taste preferences that lead to improved vegetable intake in children. Yet few studies have investigated the impact of a "vegetables first" approach to complementary feeding, especially in New Zealand. The purpose of this randomised control trial is to investigate the effect of starting complementary feeding with vegetables only on infants' later intake and liking of vegetables, compared to those starting with fruit and vegetables.

METHODS/DESIGN

One-hundred and twenty mother-infant pairs living in Auckland, New Zealand, will be randomised to receive either vegetables only (intervention) or fruit and vegetables (control) for 28 days, starting from the first day of complementary feeding at around 4-6 months of age. Infants will be presented with a brassica (broccoli), followed by a green leafy vegetable (spinach) and sweet fruit (pear) at 9 months of age. The primary outcome measures of intake of each food will be assessed using a weighed food diary. Secondary outcome measures of overall intake, liking and wanting of vegetables will be assessed using a food frequency questionnaire, liking tool and video coding tool, respectively, at 9, 12, and 24 months of age. Infant growth and iron status will be assessed as part of health screening and monitoring at baseline, post intervention and 9 months of age. Other biological samples to be collected include infant stool samples, vitamin D (mother and infant), iron status (mother), and mothers' diet.

DISCUSSION

This randomised, controlled trial will be the first to our knowledge to investigate a "vegetables first" approach to complementary feeding on infants' liking and intake of vegetables in New Zealand. Comparison against standard practice (fruit and vegetables as first foods) should complement other trials underway, such as the Baby's First Bites and Nordic OTIS trial. Results may contribute to the evidence supporting complementary feeding guidelines in New Zealand and worldwide.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registry ACTRN12619000737134 . Registered on 16 May 2019.

A quasi-experimental intervention protocol to characterize the factors that influence the acceptance of new foods by infants: mothers' diet and weaning method. Dastatuz project

BACKGROUND

Children usually refuse to eat and taste fruits and vegetables; and turning unhealthy eating habits around is an important social challenge in industrialized countries. The Dastatuz project aims to study children food neophobia and to enhance fruit and vegetable acceptance.

METHODS

A quasi-experimental, multicentre, controlled and prospective intervention study is proposed, in which early factors influencing new food acceptance will be studied. Mothers in the third trimester of pregnancy (n = 144) and their infants will be the study population. Experimental groups will be established based on mothers´ fruit and vegetable intake (standard or high intake) and weaning method (baby lead weaning vs spoon feeding). The project will assess the possible impact of maternal diet and complementary feeding on infants eating behaviour until 18 months of age. Outcome measures will comprise maternal diet and psychological features during pregnancy and breast-feeding (validated questionnaires). Compositional and physicochemical analysis of milk during breastfeeding will also be carried out. During weaning, until 18 months of age, children's diet will be assessed with 24 h recalls and acceptance of new fruits and vegetables will be studied using video recording.

DISCUSSION

If the intervention is effective, this research work would have a high potential to be transferred to future public health programs or nutrition guidelines, as a feasible solution to achieve a higher intake of fruits and vegetables among children.

TRIAL REGISTRATION

This study is registered at ClinicalTrials.gov. Identifier: NCT04262102 . Registration date: February 10, 2020 - Retrospectively registered.

Non-invasive Biometrics and Machine Learning Modeling to Obtain Sensory and Emotional Responses from Panelists during Entomophagy

Insect-based food products offer a more sustainable and environmentally friendly source of protein compared to plant and animal proteins. Entomophagy is less familiar for Non-Asian cultural backgrounds and is associated with emotions such as disgust and anger, which is the basis of neophobia towards these products. Tradicional sensory evaluation may offer some insights about the liking, visual, aroma, and tasting appreciation, and purchase intention of insect-based food products. However, more robust methods are required to assess these complex interactions with the emotional and subconscious responses related to cultural background. This study focused on the sensory and biometric responses of consumers towards insect-based food snacks and machine learning modeling. Results showed higher liking and emotional responses for those samples containing insects as ingredients (not visible) and with no insects. A lower liking and negative emotional responses were related to samples showing the insects. Artificial neural network models to assess liking based on biometric responses showed high accuracy for different cultures (>92%). A general model for all cultures with an 89% accuracy was also achieved.

UK mothers' experiences of bottle refusal by their breastfed baby

Little is known about bottle refusal by breastfed babies; however, an informal review of global online forums and social media suggested large numbers of mothers experiencing the scenario. This study aimed to explore UK mothers' experiences of bottle refusal by their breastfed baby in order to provide understanding of the scenario and enhance support for mothers experiencing it. A 22‐point online questionnaire was developed and completed by 841 UK mothers. Findings suggest that mothers introduced a bottle to their breastfed baby due to physical, psychological and socio‐cultural factors. Advice and support for mothers experiencing bottle refusal was not always helpful, and 27% of mothers reported bottle refusal as having a negative impact on their breastfeeding experience. When compared with eventual bottle acceptance, bottle refusal was significantly associated with previous experience of bottle refusal (p < .001), how frequently mothers intended to feed their baby by bottle and babies being younger at the first attempt to introduce a bottle (p < .001). This study provides a unique insight into the complexities of bottle refusal by breastfed babies and the impact it can have upon mothers' breastfeeding experiences. It generates knowledge and understanding that can help to inform practice and policies. In addition, a ‘normalising’ of the scenario could enable mothers, and those supporting them, to view and manage it more positively.