What is the question?

• The question is: What is the relationship between caregiver feeding practices for children from birth to 24 months old and the weight, growth, and body composition outcomes?

What is the answer to the question?

• Moderate evidence from randomized controlled trials suggests that providing responsive feeding guidance to mothers to recognize and respond appropriately to a child’s hunger and satiety cues can contribute to “normal” weight gain and/or “normal” weight status in children two years and younger compared to children whose mothers did not receive responsive feeding guidance. 
• Moderate evidence from longitudinal cohort studies indicates an association between maternal feeding practices and the child’s weight status and/or weight gain, but the direction of effect has not been adequately studied. Restrictive feeding practices are associated with increased weight gain and higher weight status and pressuring feeding practices are associated with decreased weight gain and lower weight status. Evidence suggests mothers' feeding practices are related to concerns about children’s body weight.

Why was this question asked? 

• This important public health question was identified and prioritized as part of the U.S. Department of Agriculture and Department of Health and Human Services Pregnancy and Birth to 24 Months Project.

How was this question answered? 

• A team of staff from the Nutrition Evidence Systematic Review conducted a systematic review in collaboration with a group of experts called a Technical Expert Collaborative

What is the population of interest? 

• Caregiver feeding practices were studied when generally healthy infants and toddlers were between the ages of 0 to 24 months; growth, size, and body composition outcomes were examined in the children through 18 years of age.

What evidence was found? 

• 27 publications were included: 6 RCTs, 2 non-randomized controlled trials, 19 longitudinal cohort studies
  • Feeding practices were examined when children were newborns to 22 months of age; outcomes were collected in children up to 6 years of age. 
• 4 controlled trials demonstrated that interventions that taught parents about responsive feeding led to lower weight outcomes in children two years and younger compared to children in a control group. 
• The longitudinal cohort studies examined a variety of feeding practices, including: pressuring, restriction, responsive, feeding in the absence of hunger, indulgent, concern about weight/intake, baby led vs. standard weaning, control, monitoring, modelling, laissez-faire, and authoritative.
• While there were some inconsistencies, there is evidence that restrictive feeding practices are positively associated with higher child weight outcomes and pressuring-to-eat practices are associated with lower child weight outcomes.
• The relationship between caregiver feeding practices and child’s weight is not unidirectional. Evidence indicates that parental concern of child’s weight is related to the child’s weight status and influences their feeding practices.
• There are limitations in the evidence, including inconsistent methodology, including the interventions, exposures, outcomes, child age, and time to follow-up, and lack of information on caregiver motivations in decision-making related to infant feeding.

How up-to-date is this systematic review? 

• This review includes literature from 01/1980 to 01/2017.

Background

• The relationship between caregiver feeding practices and child weight outcomes is likely bi-directional and influenced by the child’s actual or perceived weight and behaviors during feeding, as well as maternal variables; this review focuses on studies that measured caregiver feeding practices as the independent variable and children weight as the outcome. 
• Feeding practices are the strategies or behaviors parents use to direct child eating.
• Responsive feeding is characterized by caregiver guidance and recognition of the child’s cues of hunger and satiety.
• Non-responsive feeding is dominated by a lack of reciprocity between the parent and child, with the caregiver taking excessive control of the feeding situation (pressuring or restricting food intake), the child controlling the feeding situation (indulgent feeding), or the caregiver being uninvolved during meals (uninvolved feeding/ laissez-faire), using feeding as a default first response to infant distress (feeding to soothe).
• Systematic reviews were conducted as part of the U.S. Department of Agriculture and Department of Health and Human Services Pregnancy and Birth to 24 Months Project. 
• The goal of this systematic review was to examine the following question: What is the relationship between caregiver feeding practices for children from birth to 24 months old and the weight, growth, and body composition of their children?

Conclusion Statement and Grade

• Moderate evidence from randomized controlled trials suggests that providing responsive feeding guidance to mothers to recognize and respond appropriately to a child’s hunger and satiety cues can contribute to “normal” weight gain and/or “normal” weight status in children two years and younger compared to children whose mothers did not receive responsive feeding guidance. Grade: Moderate
• Moderate evidence from longitudinal cohort studies indicates an association between maternal feeding practices and the child’s weight status and/or weight gain, but the direction of effect has not been adequately studied. Restrictive feeding practices are associated with increased weight gain and higher weight status and pressuring feeding practices are associated with decreased weight gain and lower weight status. Evidence suggests mothers' feeding practices are related to concerns about children’s body weight. Grade: Moderate

Methods 

• This systematic review was conducted by a team of staff from the Nutrition Evidence Systematic Review in collaboration with a Technical Expert Collaborative. 
• Literature search was conducted using 4 databases (PubMed, Cochrane, Embase, and CINAHL) to identify articles that evaluated the intervention or exposure of caregiver feeding practices and the outcomes of growth, size, and body composition. A manual search was conducted to identify articles that may not have been included in the electronic databases searched. Articles were screened by two authors independently for inclusion based on pre-determined criteria. 
• Data extraction and risk of bias assessment were conducted for each included study, and both were checked for accuracy. The body of evidence was qualitatively synthesized to inform development of a conclusion statement(s), and the strength of evidence was graded using pre-established criteria evaluating the body of evidence on internal validity/risk of bias, adequacy, consistency, impact, and generalizability.

Summary of Evidence

• Twenty-seven articles (6 RCT, 2 non-randomized controlled trials, 19 longitudinal cohort studies) met criteria for inclusion that examined caregiver feeding practices and child growth, size, and body composition outcomes
• Studies took place in the U.S., Australia, the U.K., the Netherlands, and China. 
• Feeding practices were examined when children were newborns to 22 months of age; outcomes were collected in children up to 6 years of age. 
• Caregivers were predominantly mothers (99%), many of whom were educated to at least the high school level.
• 4 controlled trials demonstrated that interventions that taught parents about responsive feeding led to lower weight outcomes in children two years and younger compared to children in a control group.
• The longitudinal cohort studies examined a variety of feeding practices, including: pressuring (n=8),   restriction (n=7), responsive (n=6), feeding in the absence of hunger (n=3), indulgent (n=2), concern about weight/intake (n=2), baby led vs. standard weaning (n=1), control (n=1), monitoring (n=1), modelling (n=1), laissez-faire (n=1), and authoritative (n=1 ).
• While there were some inconsistencies, there is evidence that restrictive feeding practices are positively associated with higher child weight outcomes (WAZ, WLZ, BMIZ, and risk of overweight  ) and pressuring-to-eat practices are associated with lower child weight outcomes (WAZ, excess weight (WAZ >1; WAZ >90th percentile), WLZ, standardized weight, and weight gain).
• The relationship between caregiver feeding practices and child’s weight is not unidirectional.  Evidence indicates that parental concern of child’s weight is related to the child’s weight status and influences their feeding practices.
• There are limitations in the evidence, including: 
  • Inconsistencies in methodology, including the interventions, exposures, outcomes, child age, and time to follow-up
  • Lack of information on caregiver motivations for making decisions about infant feeding 
  • Lack of information on the stability of feeding practices over time or throughout different developmental periods, particularly during the transition from breast or bottle-feeding to feeding complementary foods and beverages