Development of the responsiveness to child feeding cues scale

Abstract

Parent–child feeding interactions during the first 2 years of life are thought to shape child appetite and obesity risk, but remain poorly studied. This research was designed to develop and assess the Responsiveness to Child Feeding Cues Scale (RCFCS), an observational measure of caregiver responsiveness to child feeding cues relevant to obesity. General responsiveness during feeding as well as maternal responsiveness to child hunger and fullness were rated during mid-morning feeding occasions by three trained coders using digital-recordings. Initial inter-rater reliability and criterion validity were evaluated in a sample of 144 ethnically-diverse mothers of healthy 7- to 24-month-old children. Maternal self-report of demographics and measurements of maternal/child anthropometrics were obtained. Inter-rater agreement for most variables was excellent (ICC > 0.80). Mothers tended to be more responsive to child hunger than fullness cues (p < 0.001). Feeding responsiveness dimensions were associated with demographics, including maternal education, maternal body mass index, child age, and aspects of child feeding, including breastfeeding duration, and self-feeding. The RCFCS is a reliable observational measure of responsive feeding for children <2 years of age that is relevant to obesity.

Introduction

Obesity is a pressing threat to both US adults and children, where increasing numbers of the youngest segment of the population are being affected. Nationally representative data indicate that in 2009–2010, 9.7% of children aged 0–2 years were obese (⩾95th% weight-for-length), with Hispanics having the highest prevalence at 14.8% and non-Hispanic Whites having the lowest at 8.4% (Ogden, Carroll, Kit, & Flegal, 2012). Many obese infants will not “grow out of it”. Heavy infants and those who show rapid weight gain are at increased risk for obesity in later periods of development (Brisbois, Farmer, & McCargar, 2012). For example, in a retrospective study of 184 older overweight children (⩾85th% Body Mass Index (BMI)), the median age of overweight onset was 15 months, with 25% overweight by 3 months (Harrington et al., 2010). Thus, the first 2 years of life are increasingly recognized as an important target for prevention efforts (Committee on Obesity Prevention Policies for Young Children, 2011, Paul et al., 2009).

The first few years of life involve major transitions in children’s eating skills as they move from complete dependence on the caregiver during infancy to relatively autonomous eating by toddlerhood. Throughout this time, however, children are dependent on their caregivers for adequate and appropriate nutrition. Caregiver feeding patterns that are unresponsive to infant hunger and/or fullness cues are thought to contribute to over-nutrition by promoting eating in the absence of hunger and/or eating beyond fullness, respectively (Bruch, 1981, Costanzo and Woody, 1985, DiSantis et al., 2011, Hurley et al., 2011, Wright, 1981, Wright, 1987). Alternatively, child-centered feeding approaches that are responsive to a child’s hunger and fullness cues are thought to support developing control of appetite, and specifically the ability to attend to internal biologically-driven cues or sensations when eating (DiSantis et al., 2011, Hurley et al., 2011). This view of parental responsiveness to child feeding draws on broader developmental definitions of parental responsiveness and sensitivity (Ainsworth and Bell, 1969, Ainsworth et al., 1974, Bornstein, 1989, Lamb and Easterbrooks, 1981), and has three components: (1) perception of the child’s cue, (2) accurate interpretation of the cue, and (3) appropriate response to the cue. Responsiveness to child feeding cues is also part of a broader definition of responsive feeding which considers the structure, routine, and emotional context provided by the caregiver (Black and Aboud, 2011, Engle et al., 2000).

To date, much of the work linking responsive parenting to child obesity has been conducted with preschool aged children (Hurley et al., 2011) and has relied on parental self-reports of child feeding styles and practices (Birch et al., 2001, Hughes et al., 2005, Musher-Eizenman and Holub, 2007, Wardle et al., 2002). In general, unresponsive feeding practices appear to have counterproductive effects on dimensions of eating behavior (Ventura & Birch, 2008) and have been modestly associated with obesity among preschool aged children in middle-to-high income countries (Hurley et al., 2011). Responsiveness to feeding cues is implicit in this body of research as well as in a more limited number of studies of children under 2 years of age. For example, higher level of maternal control during feeding, when assessed through self-report (Brown & Lee, 2011a), has been positively associated with infant weight gain. The same relationship has been found when assessing maternal control during feeding through observation (Farrow & Blissett, 2006), but only for those infants with high weight gain in the first 6 months of life. However, maternal pressure to eat and restriction at 1 year predicted lower weight at 2 years when controlling for weight at 1 year (Farrow & Blissett, 2008). In other work, baby-led weaning, in which infants are allowed to self-feed complementary foods from the outset of introduction (as opposed to being spoon fed by a caregiver) has been associated with lower maternal control during feeding (Brown & Lee, 2011b) and, alternatively, greater food acceptance and lower weight (Townsend & Pitchford, 2012). The findings of these studies are certainly consistent with those in older children and suggest a role of responsive feeding in infant over-nutrition. However, to date, few studies have explicitly assessed child feeding cues and the responsiveness of feeding initiation and termination to those cues, particularly in the first 2 years of life (Agras et al., 2012, DiSantis et al., 2011).

This paper reports the development and initial psychometric evaluation of an observational measure of caregiver responsiveness to child hunger and fullness cues during the first 2 years of life. An observational approach was taken because caregiver self-reports of feeding behavior have been found to differ from observed feeding behaviors (Lewis and Worobey, 2011, Sacco et al., 2007), and the latter are thought to capture behaviors that may not be reported or considered salient in self-reports of feeding interactions, but that may nonetheless have an important influence on children’s eating development. There are a number of existing observational measures of feeding interactions in early development, including the Nurse Child Assessment Feeding Scale (NCAFS; (Sumner & Spietz, 1994), the Feeding Scale (Chatoor et al., 1997), and the Parent Child Early Relational Assessment (PCERA; (Clark, 1999)), and the Feeding Interaction Scale (FIS; (Wolke, Sumner, McDermott, & Skuse, 1987)). These measures have primarily been used clinically to evaluate eating pathology in the case of growth faltering (The Feeding Scale, FIS) or to study broader interaction quality (NCAFS, PCERA, FIS) rather than to examine specific feeding behaviors and interactions around child hunger and fullness cues. In addition, the use of the NCAFS and PCERA is limited to the first year of life. Thus, the aim of this research was to develop the Responsiveness to Child Feeding Cues Scale (RCFCS), an observational measure of dyadic feeding interactions with relevance for developing controls of appetite and obesity for caregivers of children under 2 years of age. A provisional coding scheme of the RCFCS was piloted and refined. A study of ethnically-diverse mothers of healthy infants and toddlers was then conducted to evaluate inter-rater agreement and preliminary criterion validity associations of the RCFCS with child/maternal anthropometrics and family demographics.