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Baby-Led Weaning
The traditional method of complementary feeding, which begins at approximately 6 months of age, is to serve purees, spoon-fed by the caregiver, and gradually increase the flavors and consistency of foods until approximately 12 months of age, when the child transitions to the family diet [17]. Baby-led weaning, introduced in England in 2008, provides softened, bite-size foods directly to the child. Children choose when and what food they will eat (from a choice of healthy options), the rhythm of the meal, and the amount of food that they will eat while primarily feeding themselves [18]. Baby-led weaning is based on presumptions that young children have the motor skills to self-feed, along with the regulatory skills to signal hunger and satiety. Caregivers play supportive, rather than direct roles, with infants often seated with the family during meals, which facilitates modeling and enables toddlers to be included in mealtime interactions.
Three recent reviews [18–20] found that baby-led weaning typically occurs in the context of the family meal, with the child consuming food that is softened and cut into bite sizes. In comparison with traditional methods of complementary feeding, baby-led weaning was positively associated with infants’ self-regulation and satiety, with timing of the initiation of complementary feeding consistent with guidelines, and with adequacy of weight gain, with some evidence of overweight among the spoon-fed group and of underweight among the baby-led group. Although there were no group differences in rates of choking or micronutrient intake, there was some suggestion that the baby-led group was at higher risk of choking and of not obtaining adequate micronutrients, often because micronutrient-rich food was offered infrequently [18]. Advantages of baby-led weaning included exposure to a wide variety of food, more interaction with the food, and exploration of multiple textures. Baby-led weaning has been adopted by families in many countries, including England, New Zealand, and Brazil, for example. Evidence addressing the nutrient intake and long-term impact of baby-led weaning on children’s nutrient intake and eating patterns is emerging.
Food Neophobia
Food neophobia, defined as refusal or fear to eat unfamiliar foods, is a normal developmental phase during toddlerhood that declines during childhood. From an ethological perspective, neophobia is adaptive because it protects children from novel foods that may be harmful or bitter. Food neophobia differs from selectivity or pickiness, defined as specific food preferences and dislikes, regardless of familiarity. A recent systematic review and meta-analysis of neophobia and picky eating emphasized the relevance of considering the social context and bidirectional parent-toddler aspects of feeding, including factors at the biological, child, parent, and household levels [21].
Evidence has shown that 10 or more presentations of the novel food may be necessary to overcome neophobia [21]. Food neophobia is often managed through familiarity and modeling with family members eating the novel foods. If familiarity and modeling are not effective, caregivers may remove the novel food from the toddler’s diet or attempt to force the toddler to eat the novel food. Limiting the toddler’s food choices denies access to healthy foods and teaches the toddler the power of refusal. Using force or pressuring techniques may increase resistance and lead to confrontational mealtimes, particularly among children who are temperamentally difficult.
Fig. 1. Responsive feeding.
Neophobia can transition into pickiness, especially if caregivers attempt to use controlling or coercive strategies. The autonomy that toddlers have developed makes them want to be agents of their own preferences and actions [22]. They may resist food that looks or smells unfamiliar or unappealing or because they can resist. If their resistance results in conflict, a negative pattern may result whereby caregivers perceive the toddler to be resistant or picky, and they then implement maladaptive strategies. A reconceptualization of neophobia has been suggested to consider the roles and perceptions of both caregivers and toddlers, to reduce the tension in their interaction, to move away from the “picky eater” term, and to focus on caregivers’ expectations of children’s eating and mealtime interactions [22].
Responsive Feeding
Responsive feeding, a derivative of responsive parenting, is based on the principle that feeding young children is bidirectional and guided by toddlers’ internal sense of hunger and satiety. Responsive feeding is embedded in a parenting style that includes both structure and responsivity [23]. The structure refers to caregivers’ establishing routines, with consistent meal patterns, timing, context, food choices, and expected behavior (e.g., eating food, no throwing food). Distractions, such as television and other screens, are removed, and meals are coordinated with others eating to provide appropriate modeling (Fig. 1). Responsivity is guided by the caregiver’s perceptions of the toddler’s characteristics, including size, health, feeding skills, and especially by the toddler’s signals of hunger and satiety. Caregiver responses are prompt, clear, nurturant, and developmentally appropriate. When the toddler signals satiety, the caregiver ends the meal and maintains a pleasant demeanor.
Fig. 2. Food parenting practices: coercive control, structure, and autonomy support [24].
A recent review identified 3 food parenting practices used with young children, including toddlers: coercive control, structure, and autonomy support (Fig. 2) [24]. Coercive control refers to controlling practices, including pressure to eat, threats, and bribes, and using food to control negative emotions. Structure refers to rules and limits, limited/guided choices, monitoring, meal- and snack time routines, modeling, food availability and accessibility, and food preparation. Autonomy support includes facilitating self-feeding, child involvement, and encouragement. The structure and autonomy support constructs are consistent with responsive feeding guidelines.
In spite of global recommendations that responsive feeding be implemented, there is no consensus on measures to be used to measure responsive feeding. A recent review identified 15 instruments developed for children from birth to 2 years of age and 28 for children aged 3–5 years [25]. Only 3 of the 43 instruments showed rigorous validation and reliability testing. Most relied on caregiver report and had not been validated against observations. There is clearly a need for a validated assessment of responsive feeding for toddlers to facilitate communication across investigations and the evaluation of intervention trials.
In summary, toddlerhood is a transitional period that can be both joyful and challenging, as children acquire new skills and assert their autonomy. Feeding is particularly challenging because there are clear expectations for caregivers to ensure that their toddlers receive adequate nutrients. Recently recognized strategies, including baby-led weaning, may facilitate the transition to complementary