Responsive Feeding

AAPCH

The Australian Association of Parenting and Child Health (AAPCH) is an international organisation of key agencies in Australia and New Zealand providing early parenting education, guidance and support for professionals working with families and young children. AAPCH is committed to optimising the physical, social and emotional health and wellbeing of children.

AIM

AAPCH strongly believe that all clinical interventions, parental education and/or guidance should be informed by reliable evidence-based studies and enhance the
parent-child relationship. Consistent advice and information to parents and caregivers on feeding in the context of responsive parenting is imperative across all
sectors.

Adequate nutrition during infancy and early childhood is essential to ensure the growth, health and development of children to their full potential (WHO, 2019; NHMRC, 2013). The Convention on the Rights of the Child (UN General Assembly, 1989) recognizes the child’s right to the highest standard of health through the important role in establishing healthy food choices and behaviours.

AAPCH recognises that professionals play a key role in promoting and advocating for parents/caregivers to use a responsive feeding approach as well as promoting optimal nutrition for families.

This position paper, (in alignment with the AAPCH Position Statement: Responsive Parenting 2018) seeks to provide guidance on the importance of responsive feeding in the early years of life. It aims to encourage feeding children in a way that is respectful of a healthy child’s ability to regulate their own appetite and supports the development of life-long healthy food references and dietary habits (Dudley, Cotton & Peralta, 2015)

Responsive feeding recognises the reciprocity between the child and caregiver during the feeding process (Perez-Escamilla et al., 2017). There are three
interrelated stages of responsive feeding (Figure 1).

The three interrelated stages of responsive feeding.

KEY PRINCIPLES FOR RESPONSIVE FEEDING

Healthy children are born with the ability to know how much they need to eat to grow (Estes, 2018). Early childhood is an ideal period for prevention and early
intervention of overweight or obesity in children particularly as food preferences and dietary habits are firmly established in the early years of life (Figure 2).

The Healthy Kids for Professionals website (NSW Health, 2019) says health professionals need to be able to:
• “understand the health and social impacts of children above a healthy weight;
• accurately assess a child’s weight status and identify children above a healthy weight;
• sensitively discuss the issue of weight status with families;
• communicate key lifestyle messages sensitively to parents;
• provide children and families with resources and practical support to make positive lifestyle changes; and
• refer children and families in their local area to specialist services and programs

PHYSICAL, SOCIAL AND EMOTIONAL DEVELOPMENT OF THE CHILD

Having a healthy weight reduces a child’s chance of having an unhealthy weight as an adult. Growth faltering in childhood can have a lasting effect on growth and may cause developmental delay if not reversed (Sheehan, 2018).

At the other end of the spectrum, overweight and obesity in children are among the most important risks to children’s long and short-term health (AIHW, 2017).
Since 2012, all Australian jurisdictions agreed to adopt the World Health Organization (WHO) growth charts for Australian children aged 0 to 2 years. The WHO charts show optimal growth and are recommended for all infants 0 to 2 years; whether breastfed or formula fed, and for all ethnic groups. In Australia, the
National Health and Medical Research Council Australian Dietary Guidelines (2013) recommend the use of the US Centers for Disease Control (CDC) weight, height and BMI charts for monitoring growth in children and adolescents aged 2 to 18 years.

During the first few weeks to months of life feeding gradually changes from a reflexive to a learnt behaviour. The progression from reflexive to voluntary independent feeding occurs along a developmental continuum involving a complex interplay between the child’s motor, sensory, cognitive, social and emotional development and their mealtime or feeding environment (Royal Children’s Hospital, Melbourne, n.d.).

Breastfeeding is the normal way of providing young infants with the nutrients they need for healthy growth and development. The family, the health care system and society at large have a role in supporting breastfeeding. Exclusive breastfeeding is recommended up to 6 months of age, with continued breastfeeding along with appropriate complementary foods up to two years of age or beyond (NHMRC, 2012). Responsive breastfeeding involves a mother responding to her baby’s cues, as well as her own desire to feed her baby. (UNICEF, 2016)

THE PARENT CHILD RELATIONSHIP

The provision of nutrition is an important interactive social experience between child and parent/carer. Parents play a key role in the development of their child’s dietary preferences and eating behaviours (Finnane et al., 2017).

It is now known that decisions about what and how to feed are the result of multifaceted interactions between a family’s’ culture, perceptions, level of education and resources. Understanding these intersecting beliefs and practices is important for creating effective, culturally informed food choices and eating practices. (Steinman et al., 2010)

Appropriate feeding practices stimulate bonding with the caregiver and psychosocial development (WHO, 2019). In responsive feeding the parent-child relationship and parent’s capacity to be mindful of the child’s signals is imperative (Hodges et al. 2014). Good parental interaction with the child is important, balanced with an understanding that a child should be encouraged to feed themselves and decide when they have had enough (Satter, 2018).

Feeding responsiveness recognises that feeds are not just nutrition, but also for love, comfort and reassurance between baby and mother. Primary caregivers who are available and responsive to an infant’s needs allow the child to develop a sense of security. The infant knows that the caregiver is dependable, which creates a secure base for the child to then explore the world (Ainsworth, 1991).

For bottle fed infants the relationship is helped if the parent/carer is supported to
tune in to feeding cues and to hold their babies close during feeds. Offering the bottle in response to feeding cues, gently inviting the baby to take the teat, pacing
the feeds and avoiding forcing the baby to finish the feed can help ensure a positive experience.

Children who grow up in families that enjoy a variety of nutritious food are more likely to make their own healthy choices as they get older. For children to eat well, parents must feed well (Satter, 2018). Meals are shared in a predictable environment which is calm and provides gentle encouragement to try foods and enjoy the meal time. A great time to be together and interact creating a mealtime environment that is safe, conducive to eating (Satter, 2018).

By promoting responsive feeding professionals play a key role in improving the quality of the attachment relationship between parent/carer and child as well as fostering healthy nutritional choices leading to better health outcomes for families and the wider community.

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REFERENCES

Ainsworth M.D.S. (1991). Attachments and other affectional bonds across the life cycle. In C.M. Parkes, J. Stevenson-Hinde & P. Marris (eds.), Attachment across the life cycle. Routledge, London, pp. 33-51. Australasian Association Parenting and Child Health (AAPCH). (2018). Position Statement: Responsive Parenting.
https://www.aapch.com.au/media/1110/1726_aapch_positionstatement_responsive-parenting_final-may-2018.pdf

Australian Institute of Health and Welfare (AIWH). (2017). A picture of overweight and obesity in Australia 2017. (Cat. no.PHE 216). Canberra, AIHW, https://www.aihw.gov.au/getmedia/172fba28-785e-4a08-ab37- 2da3bbae40b8/aihw-phe-216.pdf.aspx?inline=true Daniels, L., Magarey, A., Battistutta, D., Nicholson, J., Farrell, A., Davidson, G. & Cleghorn, G. (2009). The NOURISH randomised control trial: Positive feeding practices and food preferences in early childhood – A primary prevention program for childhood obesity. BMC Public Health, 9. 387. DOI:10.1186/1471-2458-9-387. Dudley, D.A., Cotton, W.G. & Peralta, L.R. (2015). Teaching approaches and strategies that promote healthy eating in primary school children: a systematic review and meta-analysis. The International Journal of Behavioral Nutrition and Physical Activity, 12, 28. DOI:10.1186/s12966-015-0182-8 Finnane, J. Jansen, E. Mallan, K. & Daniels, L. (2017). Mealtime structure and responsive feeding practices are associated with less food fussiness and more food enjoyment in children. Journal of Nutrition Education and Behavior, 49(1), 11-18.e1. http://dx.doi.org/10.1016/j.jneb.2016.08.007 Hodges, E.A., Johnson, S.L., Hughes, S.L., Hopkinson, N.F., Butte, N. & Fisher, J. (2014). Development of the Responsiveness to Child Feeding Cues Scale. Appetite, 65, 210-219. doi: 10.1016/j.appet.2013.02.010>. National Health and Medical Research Council (NHMRC). (2013). Eat for Health: Infant Feeding Guidelines- Information for Health Workers. NHMRC, Canberra. ttps://www.eatforhealth.gov.au/sites/default/files/content/The%20Guidelines/170 131_n56_infant_feeding_guidelines_summary.pdf NSW Health. (2017). Growth Assessment in Children and Weight Status Assessment in Adults. http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2017_021.pdf NSW Health. (2019). ealthy Kids for Professionals. https://www.healthykids.nsw.gov.au/campaigns-programs/healthy-kids-forprofessionals.aspx Pérez-Escamilla, R., Segura-Pérez, S. & Lott, M. (2017). Feeding Guidelines for Infants and Young Toddlers: A Responsive Parenting Approach. Durham, NC.