Maternal decisions about the initiation and termination of infant feeding

Abstract

Caregiver responsiveness to infant hunger and fullness cues is thought to play a role in the development of overweight during infancy, but this aspect of infant feeding has received little study. This research used a qualitative approach to understand aspects of feeding responsiveness involving maternal perception and interpretation of infant feeding cues by asking mothers about factors they used to initiate and terminate infant feeding. Participants were 71 ethnically diverse mothers of healthy, term infants at 3, 6, or 12 months of age. Mothers were asked three questions about feeding initiation and termination. Qualitative content analysis was used to derive major themes. Results revealed that the extent to which infant cues were prominent in maternal approaches to feeding was variable. Some mothers focused on amount consumed or eating schedule whereas others reported sole orientation to infant state and/or oral behaviors. Other themes involved the range of intensity and specificity of the infant cues that prompted feeding initiation and termination. The qualitative findings suggest that mothers may differ in the extent to which they perceive and rely upon infant hunger and fullness cues to initiate and terminate feeding.

Introduction

A primary goal of parenting in the early years of life is to support appropriate child growth and development. That 10% of infants and toddlers are overweight, with the prevalence as high as 18% among non-Hispanic black children (Ogden, Flegal, Carroll, & Johnson, 2002), suggests that this goal is not being met for many. Overweight is recognized as a multifactorial problem of energy balance involving genes, environment, and behavior. One context in which these factors come together is the daily feeding interactions between parent and child. The human infant is born dependent upon caregivers to meet their nutritional needs, underscoring the importance of dyadic feeding interactions for the infant's early nutritional health and growth. The enduring nature of this dependency in early development implicates dynamics involving feeding initiation and termination as modifiable contributors to overnutrition.

Responsiveness to infant hunger and satiety cues is a central dimension of responsive feeding, which refers to broad aspects of caregiving behavior believed to support healthy food intake and growth (Ainsworth & Bell, 1969; Engle, 1999; Engle, Bentley, & Pelto, 2000). Previous work on responsive feeding has focused primarily on caregiving behaviors (e.g., encouraging eating) germane to the prevention of child malnutrition and growth stunting, with relatively little attention given to the parallel role of responsiveness in child overnutrition and overweight. Responsiveness to infant hunger and satiety cues is central to the idea that a chronic mismatch of infant state and caregiver feeding behavior may alter the child's learned self-regulation of eating and increase the risk of overweight (Birch & Fisher, 1998; Bruch, 1973; Costanzo & Woody, 1985). Consistent with a conceptualization of responsive parenting from the child development literature (Lamb & Easterbrooks, 1981), responsive feeding necessitates perception, accurate interpretation, and appropriate response to the infant's hunger and fullness cues at any given point in development. Each of these aspects of feeding responsiveness deserves further explication. Perception involves the caregiver's awareness of the infant's cues. Accurate interpretation involves the correct assignment of meaning to a cue such that a hunger cue is understood to be a hunger cue and not, for example, an indication of pain or a desire to play. Finally, in the context of feeding, appropriate response, at the most basic level, involves feeding in response to hunger cues and cessation of feeding in response to fullness cues.

Empirical description of infant hunger and fullness behaviors, as well as maternal responses to these behaviors, particularly in the context of overnutrition, is limited. Mouthing appears to be hunger related (Korner, Chuck, & Dontchos, 1968) while slowing of eating pace, becoming sleepy, taking interest in surroundings, refusing nipple/food, and spitting have been identified as satiation cues (Crow, 1977; Morris, Rogers, & Taper, 1983). Little else is documented regarding the temporal sequencing, normal variability, and developmental progression of hunger and fullness cues during infancy. Moreover, the extent to which mothers rely upon such cues to initiate and terminate feeding is not well elucidated. Prior qualitative research has suggested that infant crying and/or perceived infant interest in adult foods can prompt the early introduction of solids (Anderson et al., 2001; Bentley, Gavin, Black, & Teti, 1999). While this research suggests ways in which infant behaviors may influence maternal decisions regarding timing of solid introduction, it does not address responsiveness to infant feeding cues during daily feeding interactions over the course of the infant's development. In a recent observational study, low to moderate maternal control (restriction of intake or pressure to eat) during solid feeding at 6 months was found to predict infant weight gain over the next 6 months, with early rapid gainers decelerating and early slow gainers accelerating in their rate of weight gain (Farrow & Blissett, 2006). While that study used an observational approach to quantify responsive feeding, it did not provide insight into how mothers approached decisions about feeding initiation and termination.

Understanding how caregivers make decisions about when feeding begins and ends is critical to interpret feeding interactions and effectively intervene to improve feeding responsiveness. Improved feeding responsiveness during infancy and toddlerhood may, in turn, lead to effective prevention of and/or intervention in early childhood obesity. To date, little is understood about the factors that influence the initiation and termination of infant feeding. Thus, the primary aim of this study was to examine aspects of maternal feeding responsiveness involving perception and interpretation by describing infant cues and other factors reported by mothers in the initiation and termination of feeding.