key assessment

Key assessment reading logs and powerpoint

First, read the provided articles. You will read two articles per issue, making a total of 12 articles. For each article, write a reading log summary, reaction, and three questions.

The reading logs are to be done in a Microsoft office word doc.

There should be a total of 16 slides for the power point not including cover page and reference page.

Key Assessment

Section I: PowerPoint Presentation and 12 Reading Logs

Create a
PowerPoint presentation and submit
12 reading logs where you describe and discuss the following key elements of infant development.

Key Elements of Infant Development

1. Infant Feeding – Is it best to breast feed or bottle feed?

2. Infant Feeding – Is it best to feed on a schedule or “on demand?”

3. Infant Sleeping – Is it best for a baby to sleep alone in own room or to co-sleep in same bed with parents?

4. Infant Crying – Is it best to pick baby up when baby cries or to let baby cry it out? (Infant crying refers to more than just crying at bedtime. Infant crying refers to any time an infant cry.)

5. Continuity of Care – What is continuity of care and what are the pros and cons? (The continuity of care term for this course refers to the practice of keeping infants and teachers together for more than one year.)

6. Attachment Theory – What is attachment theory and why is it important?

First, read the provided articles. You will read two articles per issue, making a total of 12 articles. For each article, write a reading log summary, reaction, and three questions. You will submit these twelve reading logs along with your PowerPoint

Next, create a PowerPoint presentation. Create three slides for each issue, except for issue number 6. For issue number 6, only one slide is needed. For issues, 1 – 5, on the first slide, list main points for the first side of the issue (for example, breast feeding). On the second slide, list main points for the other side of the issue (for example, bottle feeding). On the third slide state your opinion. When you create your slides, you should use bullet points for the slides. You should not have more than 6 bullet points per slide and not more than 4 or 5 words after each bullet point. You may use the notes section of the PowerPoint to provide detailed explanations written in complete sentences.

Finally, create a final slide in your PowerPoint where you discuss how early childhood programs influence an infant’s development and what the short and long term effects of an early childhood program might be on an infant’s development. Refer to academic articles in this discussion. Feel free to include pictures or drawings to enhance your discussion.

Summary of Infant responsive feeding article:

In this article the authors use the term responsive feeding to mean feeding on demand. They suggest that if mothers do not use on demand feeding their babies will become overweight. The idea is that babies need to learn what it feels like to feel hungry. When they feel hungry they need to call out to their mothers and have their mothers respond right away by feeding them. If the mothers listen to their babies’ cues (crying) and feed them, the babies will develop self-regulation and self-control because they will learn that when they have a need the need will be met. They will learn to eat when they are hungry. Babies feel confident and secure when they signal that a need (hunger) needs to be met and then the need is actually met right then and there. If mothers try to feed their babies when they are not hungry, the babies will learn to eat when someone else thinks they should eat or just because it is a certain time, which could lead to weight problems later in life. Healthy eating is when a baby eats when she is hungry not when it is a certain time or when someone else thinks she should eat.

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University of Notre Dame

College of Arts and Letters

Mother-Baby Behavioral Sleep Laboratory

Safe Cosleeping Guidelines

Guidelines to Sleeping Safe with Infants:

Adapted from: Maximizing the chances of Safe Infant Sleep in the
Solitary and Cosleeping (Specifically, Bed-sharing) Contexts,

by
James J. McKenna, Ph.D. Professor of Biological Anthropology, Director,
Mother-Baby Sleep Laboratory, University of Notre Dame.

Below is a summary that highlights some of the issues to be concerned
with as you make your own decisions about where and how your infant
should sleep.

What constitutes a “safe sleep environment” irrespective of where the infant sleeps?

Safe infant sleep ultimately begins with a healthy gestation.
Specifically, safe infant sleep begins without the fetus being exposed
to maternal smoke during pregnancy.

A second factor that has a strong influence on safe infant sleep is
breastfeeding. Breastfeeding significantly helps to protect infants from
death including deaths from SIDS/SUDI and from secondary disease and/or
congenital conditions. Post-natally safe infant sleep begins especially
with the presence of an informed, breastfeeding, committed mother, or
an informed and committed father.

Regardless of whether an infant sleeps on the same surface as his or
her parents, on a same-surface co-sleeper, in a bassinet or in a
separate crib, in the same room as their parents or in a separate room,
all infants should follow these same guidelines: infants
should always sleep on their backs, on firm surfaces, on clean surfaces,
in the absence of (secondhand) smoke, under light (comfortable)
blanketing, and their heads should never be covered.

The bed should not have any stuffed animals or pillows around the
infant and never should an infant be placed to sleep on top of a pillow
or otherwise soft bedding.

Sheepskins or other fluffy material and especially beanbag mattresses
should never be used with infants. Waterbeds can be especially
dangerous to infants too, and no matter the type of mattress, it should
always tightly intersect the bed-frame to leave no gaps or space.
Infants should never sleep on couches or sofas with or without adults as
they can slip down (face first) into the crevice or get wedged against
the back of a couch where they may suffocate.

Bedsharing: It is important to be aware that adult beds were not designed to assure infants safety!

It is important to realize that the physical and social
conditions under which infant-parent cosleeping occur, in all it’s
diverse forms, can and will determine the risks or benefits of this
behavior. What goes on in bed is what matters.
Bottlefeeding babies should always sleep alongside the mother on a separate surface rather than in the bed.
If bedsharing, ideally, both parents should agree and feel
comfortable with the decision. Each bed-sharer should agree that he or
she is equally responsible for the infant and acknowledge before
sleeping that they are aware that the infant is present in the bed
space. Do not place an infant in the bed with a sleeping adult who is
not aware that the infant is in the bed with them. My feeling is that
both parents should think of themselves as primary caregivers.
Infants a year or less should not sleep with other/older child
siblings — but always with a person who can take responsibility for the
infant being in the bed.
Persons taking sedatives, medications or drugs, or intoxicated from
alcohol or other substances, or otherwise excessively unable to arouse
easily from sleep should not cosleep on the same surface with the
infant.
Excessively long hair on the mother should be tied up to prevent
infant entanglement around the infant’s neck (yes, this has very
unfortunately happened).
Extremely obese persons or others who may have difficulty feeling
where exactly or how close their infant is in relation to their own
body, may wish to have the infant sleep alongside but on a different
surface, such as a cosleeper attachment.
Finally, it may be important to consider or reflect on whether you
would think that you suffocated your baby if, under the most unlikely
scenario, your baby died from SIDS while in your bed. Just as babies can
die from SIDS in a risk-free solitary sleep environment, it remains
possible for a baby to die in a risk-free cosleeping/bedsharing
environment. Just make sure, as much as this is possible, that you would
not assume that if the baby died, that either you or your spouse would
think that bed-sharing contributed to the death, or that one of your
really suffocated (by accident) the infant. While this is an unpleasant
and uncomfortable topic, it is one that is worth thinking about before
you make the choice to cosleep/bedshare with your infant.

Aside from never letting an infant sleep outside the presence
of a committed adult, i.e. separate-surface cosleeping which is safe
for all infants, I do not recommend to any parents any particular
type of sleeping arrangement since I do not know the circumstances
within which particular parents live. What I do recommend is to consider
all of the possible choices and to become as informed as is possible
matching what you learn with what you think can work the best for you
and your family.

Home
Why This Website?
What We Do
Dr. McKenna’s Biography
Safe Cosleeping Guidelines
The Bedsharing Controversy
Frequently Asked Questions
Television and Documentary Videos
Articles and Presentations
Important Resources for Parents
What Every Health Professional Should Know

University of Notre Dame

Mother-Baby Behavioral Sleep Laboratory

Department of Anthropology, University of Notre Dame Notre Dame, IN 46556

james.j.mckenna.25@nd.edu

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Accessibility Information

Schedule or on demand? (Feeding schedules for babies)

Chatelaine

, English edition

68.5

(May 1995): 36.

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Like many first-time mothers, I buried myself in baby books. I knew yesterday’s rigid feeding schedules were passe. Happy babies feed on demand, said experts such as Penelope Leach.

That’s true in the first few months, when a newborn’s small stomach cannot hold much milk or formula (nursing infants need to feed every couple of hours). But by around three or four months, round-the-clock feedings are hard on parents, especially if they have other children, and may not be in the baby’s best interests. Ruth McCamus, a nurse at The Hospital for Sick Children’s Centre for Health Information and Promotion in Toronto, is a great believer in routine. “It helps to plant the idea in the baby’s mind that there is a regularity to the way things happen.”

Like many first-time mothers, I buried myself in baby books. I knew yesterday’s rigid feeding schedules were passe. Happy babies feed on demand, said experts such as Penelope Leach.
That’s true in the first few months, when a newborn’s small stomach cannot hold much milk or formula (nursing infants need to feed every couple of hours). But by around three or four months, round-the-clock feedings are hard on parents, especially if they have other children, and may not be in the baby’s best interests. Ruth McCamus, a nurse at The Hospital for Sick Children’s Centre for Health Information and Promotion in Toronto, is a great believer in routine. “It helps to plant the idea in the baby’s mind that there is a regularity to the way things happen.”

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When my daughter was born nearly two years ago, I was prepared for the worst–feedings every two hours, months of sleepless nights. But I was lucky. From birth, Lucy knew night from day and–with the exception of a brief burst of nursing enthusiasm in the evenings–fed only every three or four hours.

Routine tends to become an issue when a mother is returning to work. Day-care workers in particular often cannot cope easily with an infant who expects to feed when the spirit moves him.

If your baby has not already established a pattern by age four months–that is, you know roughly what to expect from one day to the next–then you’re wise to start encouraging one, McCamus says. But regular doesn’t necessarily mean rigid: the goal is a flexible routine that works for both of you.

Feeding without fuss

If your baby feeds well and then cries two hours later, try to postpone the breast or bottle for a while by playing with her or having a cuddle. If she’s a snacker who doesn’t feed long enough to fill up, take a break for 15 or 20 minutes. Then, offer more milk or formula.

If your baby has day/night confusion, wake him up during the day for regular feedings and playtimes every two to three hours. Keep late-night mealtimes quiet and dimly lit so as not to wake him completely. Eventually, he’ll get the message.

Don’t wake a sleeping baby in the middle of the night for a feeding unless there is a medical reason to do so, such as insufficient weight gain.

Don’t be afraid to give a feeding a little earlier than usual if your baby is clearly hungry. Similarly, if she’s content upon waking, immediate feeding may not be necessary.

Trust your instincts. Too much reliance on parenting books can cause confusion.

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Table of contents

How to get a grip on attachment theory

………………………………………………………………………………………….. 1

07 April 2016 ii ProQuest

Document 1 of 1

How to get a grip on attachment theory
Author: Townshend, Kate
ProQuest document link
Abstract: […]I wonder how many of us are really clear about what attachment theory is. “The preliminary
evidence from our pilot study shows that attachment-based practice in schools can have a positive impact on
academic performance, reduction in behavioural incidents and improvements in pupil and staff well-being.”
Full text: Behaviour issues caused by trauma are more common than you may think – but a new project is
developing strategies to help
Fresh from teacher training and on the supply circuit, I spent some time in a Reception classroom where I
discovered that size is no predictor of the severity of behaviour problems. Faced with a tiny boy who spat,
shouted and, at the age of 5, knew more swear words than I did, I was baffled, panicked and eventually angry.
Then, at lunchtime, his personal teaching assistant returned from training and my miniature Mr Hyde was
suddenly transformed into an altogether calmer Dr Jekyll, visibly relaxing after a hug and some soothing words
from the saintly Mrs M. At the time, I assumed his poor behaviour was entirely down to something I had done
wrong. But I later learned that this student was suffering from attachment issues.
Dr Maggie Atkinson, the children’s commissioner for England, believes that “every teacher in every school”
should be aware of attachment theory and tailor their practice accordingly. But I wonder how many of us do. In
fact, I wonder how many of us are really clear about what attachment theory is. I certainly wasn’t able to spot
the signs when they were right in front of me.
Be aware of the basics
British psychologist John Bowlby first articulated attachment theory (in the terms we now understand it) in the
mid-20th century. It is an attempt to explain how the relationship between a child and its parents, particularly the
mother, influences development.
Bowlby believed that in the early years of life, a child will form an attachment with a single primary care-giving
figure and that this relationship will be a prototype for all future relationships. He argued that should an
attachment fail to form during this period, or be disrupted, then a number of consequences would follow,
including behaviour problems and reduced ability to learn.
Teachers should be aware of the implications of this theory. But how prevalent is the problem and how do you
identify it? The majority of parent-child relationships appear to be strong, after all.
Fortunately, identifying children with attachment issues is possible. Schools may already be aware of
circumstances that could affect attachment. If not, resilience is often a key factor: a child who gives up at the
first sign of failure may be lacking the secure base required to try again.
And more children may be suffering from these issues than you expect. A key study on attachment, conducted
by Christi and David Bergin in 2009, estimates that up to a third of all children have an insecure attachment to at
least one caregiver. A 2004 study from Scotland, meanwhile, posits that almost all children will have
experienced trauma of some kind by the end of their primary years.
But just being aware of attachment theory is not enough: teachers need to use it to inform how they teach and
form relationships with students.
So where to begin? The Attachment Aware Schools project brings together university-based researchers and
local practitioners in Somerset to provide training on bringing ideas about attachment into classrooms (for more
information, visit www.attachmentawareschools.com).
In 2013 and 2014, the project’s organisers ran a pilot study in 11 schools and colleges, with each committing to
a programme of training in areas such as trauma and its implications for learning. Each institution devised its

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own whole-school approaches to being “attachment aware” with the help of a consultant.
The initial results were excellent, with all participants reporting that they had found the process useful and that it
had had a big impact on learning.
Dr Janet Rose of Bath Spa University is part of the research group leading the programme. She explains:
“Attachment theory is already well recognised in areas such as clinical psychology, health and social care.
“The preliminary evidence from our pilot study shows that attachment-based practice in schools can have a
positive impact on academic performance, reduction in behavioural incidents and improvements in pupil and
staff well-being.”
Putting theory into practice
So far, so good. But what does attachment theory look like in practice? And what new strategies are emerging?
One example is the use of “emotion coaching”. Originating in the US and historically used in helping parents to
relate to their children, it involves recognising, naming and validating the feelings and emotions that may cause
disruptive behaviour rather than dismissing them.
In particular, there is an emphasis on changing the language used to deal with poor behaviour, enabling
children to understand and manage their feelings more successfully.
For example, parents would be advised to say: “I’m sorry you’re feeling so angry and I’d like to talk to you more
about it, but I still need you to stop throwing things” (instead of: “It’s very silly to throw things so stop it right
now!”). It is a strategy that has been embraced by many of the pilot schools in the Attachment Aware scheme,
and Ed Harker, headteacher of St Saviours CEVC Nursery and Infant School in Bath, has already seen positive
results.
“We have found that children with attachment disorders have responded really well,” he explains. “And on a
practical level, attachment theory has changed the specific language we use with all the children.”
The Attachment Aware project and its pilot schools offer further specific ways of bringing attachment into an
educational setting, from appointing an attachment leader to using nurture groups to help children process their
feelings better.
Harker says that the interventions at St Saviours – such as a “nurture” space for children to use at lunchtime –
have had a school-wide impact.
“There is a better emotional intelligence within the school team now and a raised awareness of attachment
needs,” he says. “It gives you the understanding you need to adapt your provision and ensure that potentially
vulnerable children are helped to thrive.”
Fighting the fear
But it is not just about interventions, according to Dr Rose. What can also be effective in schools, she believes,
is the modelling of attachment. “Most teachers are likely to encounter insecurely attached and traumatised
children in their classrooms,” she says. “A warm, supportive teacher can actually promote attachment
relationships.”
Roger Catchpole, a consultant for children’s mental health charity YoungMinds, agrees: “There is strong
evidence for the protective power of one important adult in a child’s life who can provide them with unconditional
positive regard. This is often found in school.” He points out that this does not have to be a teacher and could
equally be a teaching assistant or other member of support staff.
The Attachment Aware project also recommends assigning “key adults” to needy children. These are trained
adults within the school who take a particular interest in a child, supporting their emotional development and
reducing their anxiety. And although “unconditional positive regard” may seem to suggest overlooking or
indulging poor behaviour, it is more about giving children a sense that they are liked and cared for in spite of
their behaviour.
This may make some teachers feel uncomfortable, particularly considering that adults are often advised to keep
a careful distance from students for child protection and authority. But as Harker says, if attachments are

07 April 2016 Page 2 of 4 ProQuest

“appropriate” and “secure” there is nothing to fear.
Fear is perhaps as important a factor as ignorance in stopping attachment theory being more widely
implemented in schools. We have become so guarded when it comes to children and so concerned with data
that we can forget about the importance of relationships in teaching. For those children lucky enough to get a
great start in life, this is damaging. But for those with attachment issues it can be nothing short of destructive.
Kate Townshend is a teacher at a primary school in Gloucestershire
What else?
Create an attachment-based nurture group with these detailed resources.
bit.ly/NurtureGroup
Use this mind map to identify the many issues faced by students with attachment disorders.
bit.ly/AttachmentDisorder
References
Bergin, C and Bergin, D (2009) “Attachment in the classroom”, Educational Psychology Review, 21: 141-70.
O’Connor, M and Russell, A (2004) “Identifying the incidence of psychological trauma and post-trauma
symptoms in children, A Survey of Three Clackmannanshire Schools”, Clackmannanshire Council
Psychological Service.
Subject: Children & youth; Students; Theory; Learning;
Publication title: The Times Educational Supplement
Issue: 5120
Publication year: 2014
Publication date: Nov 7, 2014
Year: 2014
Section: News
Publisher: TES Global Limited
Place of publication: London
Country of publication: United Kingdom
Publication subject: Education
ISSN: 00407887
Source type: Trade Journals
Language of publication: English
Document type: News
ProQuest document ID: 1625312946
Document URL: http://nclive.org/cgi-
bin/nclsm?url=http://search.proquest.com/docview/1625312946?accountid=11330
Copyright: Copyright TSL Education Ltd. Nov 7, 2014
Last updated: 2014-11-17
Database: ProQuest Central

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How to get a grip on attachment theory

Clearinghouse on Elementary and
Early Childhood Education

University of Illinois • 51 Gerty Drive • Champaign, IL 61820-7469 ERIC DIGEST
(217) 333-1386 • (800) 583-4135 (voice/TTY) • ericeece@uiuc.edu • http://ericeece.org December 2003 • EDO-PS-03-17

Continuity of Caregiver

for Infants and Toddlers
Debby Cryer, Sarah Hurwitz, and Mark Wolery

According to the 1999 National Survey of American
Families, an estimated 10% of infants under a year of age
are participating in center-based care and education
programs, while the numbers are higher for 1-year-olds
(16%) and 2-year-olds (24%) (Ehrle, Adams, & Tout,
2001). The practices used in caring for these infants and
toddlers may have strong and enduring impacts on
children’s development and well-being. In terms of child
care quality during the first three years, higher quality is
associated with better mother-child relationships, fewer
reports of children’s behavior problems, higher cognitive
and language outcomes, and better readiness for school
(Burchinal et al., 1996; NICHD Early Child Care Research
Network, 1996). In addition to the general quality of care
for infants and toddlers, discrete practices may influence
the development of infants and toddlers. One practice that
is currently attracting substantial interest is the provision of
continuity of caregivers for young children. Continuity of
caregivers means that infants and toddlers remain with
the same teacher(s) during a significant part, if not all, of
their first years in a program.
Continuity of Caregiver
Traditionally, young children in center-based child care
programs have a series of different caregivers during the
first three years of life. Centers often follow the lock-step
elementary school practice of moving children to a
different class/teacher at the end of the year. Many
programs move children more often, from class to class,
teacher to teacher, as soon as they attain certain
developmental milestones, such as crawling or walking.
Some programs may move children on a daily basis to
meet ratio or other staffing requirements. This practice is
often used to ensure efficient use of program resources
by keeping classes full and enrolling infants, for whom
there is more child care demand. High rates of teacher
turnover increase the likelihood that children will change
teachers repeatedly during the infant/toddler years
(Helburn, 1995; Whitebook, Howes, & Phillips, 1989).
The rationale for continuity of caregiver is similar to that for
assigning primary caregivers to very young children.
Primary caregivers take major responsibility for meeting
the care and educational needs of a small group of children,
within a larger group. Both practices, continuity of caregiver
and primary caregiver, are intended to create a consistent
personal relationship between a child and a teacher.
In these practices (primary caregiver and continuity of
caregiver), transitions between teachers are minimized
because transitions are seen as being stressful for the
child (and adults) and wasteful in terms of learning time.
When a child is moved to a new caregiver, recommended
practice suggests that strategies be used to ease transi-
tions. For example, children can visit their new class and

teacher before moving, or their new teacher can visit them
a few times so that they can get to know one another.
Theory and Research
The current professional recommendation of continuity of
caregiver for infants and toddlers is based on conclusions
drawn from child development theory and from limited
research findings. Theoretically, issues regarding the
development of secure maternal attachment are
considered paramount for infants and toddlers (Ainsworth
et al., 1978; Bowlby, 1982; Smith & Pederson, 1988).
Secure maternal relationships are associated with more
positive child outcomes, especially with regard to social-
emotional development (e.g., Matas, Arend, & Sroufe,
1978; Jacobson & Wille, 1986). There also is evidence
that maternal attachment is related to children’s language
development (Klann-Delius & Hofmeister, 1997; van
Ijzendoorn et al., 1995), cognitive development (van
Ijzendoorn et al., 1995), and emergent literacy (Bus & van
Ijzendoorn, 1988).
Some evidence suggests that in addition to attachment to
mothers, the child’s attachment to a primary caregiver in
out-of-home child care is also important (Cummings,
1980; Goossens & van Ijzendoorn, 1990; Howes &
Hamilton, 1992). Raikes’ (1993) research suggests that
children take a significant amount of time to form
attachments to caregivers, so they are less likely to form
attachments if frequent caregiver changes occur. Howes
and Hamilton (1992) found that with multiple changes in
caregivers, toddlers are less likely to relate to a new
caregiver based on her own behavior but rather re-create
the quality of the relationship with a previous caregiver.
They also report a relationship between the number of
caregiver losses experienced by a preschooler and the
likelihood that the child will be socially withdrawn or
aggressive with peers (Howes & Hamilton, 1993). It is
possible that the effects of caregiver changes might relate
to other areas of children’s development as well.
Current Practice
The extent to which children change caregivers during the
first three years in child care centers is not known, but it is
assumed to be high (Howes & Hamilton, 1993). Likewise,
little is known about the extent to which continuity of
caregiver is practiced, although reports of survey research
conducted by Cryer et al. (2000) of 273 centers indicate
that relatively few programs, whether accredited or non-
accredited, provide continuity of caregivers for infants and
even fewer provide it for toddlers.
Implementing Continuity of Caregiver
When the practice of continuity of caregiver is
implemented in child care centers, various strategies are

used. For example, the amount of time that children
remain with the same teacher might vary, with some
having the same teacher through the first and second
years, and others having the same teacher for a shorter
but extended period (e.g., 18 months). Keeping children
with the same teacher is more likely when multiage
groups are used, because having a birthday or reaching
developmental milestones does not force a change in
class. Continuity of caregiver, however, is also used with
same-age groupings. Teachers and their children may
use the same physical space through their years together,
or they may move from one classroom to another. In
classes with multiple teachers, all teachers and children
might move together, while in another setting, a subgroup
of children might move with only one of the teachers.
Thus, even within this practice (continuity of caregivers),
there can be substantial variation. Yet the major
requirement for providing continuity of caregiver is met.
To offer continuity of care for infants and toddlers, center
staff might want to consider the following suggestions:
• Avoid taking new children only in the youngest group;

this practice forces moving children up one at a time
and separates them from the teacher to whom they
are attached.

• Recruit new children to fill in at upper age levels when
it is more appropriate to have more children per adult.

• Use mixed-age groupings.
• Reward staff for longevity with the program.
• If a staff member leaves, overlap staff so that children

are never left with strangers.
Conclusion
Although positive child development effects may be
associated with the practice of continuity of caregiver, it is
certainly possible that there are also negative effects
associated with the practice. For example, if a child
spends several years with a teacher who interacts
negatively with the child, undesirable outcomes would be
likely. At this time, the actual effects associated with the
practice are based only on theoretical assumption and
limited research. Center staff may require more
compelling evidence that a practice is truly a better option
before undertaking the substantial modifications that are
required in making a significant change.
For More Information
Ainsworth, M., Blehar, M., Waters, E., & Wall, S. (1978).
Patterns of attachment: A psychological study of the Strange
Situation. Hillsdale, NJ: Erlbaum.
Bowlby, J. (1982). Attachment and loss. Vol. 1: Attachment.
New York: Basic.
Burchinal, M., Roberts, J., Nabors, L., & Bryant, D. (1996).
Quality of center child care and infant cognitive and
language development. Child Development, 67(2), 606-620.
EJ 523 402.
Bus, A. G., & van Ijzendoorn, M. H. (1988). Mother-child
interactions, attachment and emergent literacy: A cross-
sectional study. Child Development, 59(5), 1262-1272. EJ
380 597.
Cryer, D., Hurwitz, S., & Wolery, M. (2000). Continuity of
caregiver for infants and toddlers in center-based child care:
Report on a survey of center practices. Early Childhood
Research Quarterly, 15(4), 497-514. EJ 635 662.
Cummings, E. M. (1980). Caregiver stability and day care.
Developmental Psychology, 16(1), 31-37.

Ehrle, J., Adams, G., & Tout, K. (2001). Who’s caring for our
youngest children? Child care patterns of infants and
toddlers. Washington, DC: Urban Institute. ED 448 908.
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References identified with an ED (ERIC document), EJ (ERIC journal), or PS
number are cited in the ERIC database. Most documents are available in ERIC
microfiche collections at more than 1,000 locations worldwide (see
http://www.ed.gov/Programs/EROD/). They can also be ordered through EDRS:
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products, or organizations imply endorsement by the U.S. Government.

Continuity of Caregiver

Infant Feeding and Childhood Cognition at Ages 3 and 7 Years
Effects of Breastfeeding Duration and Exclusivity
Mandy B. Belfort, MD, MPH; Sheryl L. Rifas-Shiman, MPH; Ken P. Kleinman, ScD; Lauren B. Guthrie, MPH;
David C. Bellinger, PhD; Elsie M. Taveras, MD, MPH; Matthew W. Gillman, MD, SM; Emily Oken, MD, MPH

IMPORTANCE Breastfeeding may benefit child cognitive development, but few studies have
quantified breastfeeding duration or exclusivity, nor has any study to date examined the role
of maternal diet during lactation on child cognition.

OBJECTIVES To examine relationships of breastfeeding duration and exclusivity with child
cognition at ages 3 and 7 years and to evaluate the extent to which maternal fish intake
during lactation modifies associations of infant feeding with later cognition.

DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study (Project Viva), a US prebirth
cohort that enrolled mothers from April 22, 1999, to July 31, 2002, and followed up children
to age 7 years, including 1312 Project Viva mothers and children.

MAIN EXPOSURE Duration of any breastfeeding to age 12 months.

MAIN OUTCOMES AND MEASURES Child receptive language assessed with the Peabody
Picture Vocabulary Test at age 3 years, Wide Range Assessment of Visual Motor Abilities at
ages 3 and 7 years, and Kaufman Brief Intelligence Test and Wide Range Assessment of
Memory and Learning at age 7 years.

RESULTS Adjusting for sociodemographics, maternal intelligence, and home environment in
linear regression, longer breastfeeding duration was associated with higher Peabody Picture
Vocabulary Test score at age 3 years (0.21; 95% CI, 0.03-0.38 points per month breastfed)
and with higher intelligence on the Kaufman Brief Intelligence Test at age 7 years (0.35;
0.16-0.53 verbal points per month breastfed; and 0.29; 0.05-0.54 nonverbal points per
month breastfed). Breastfeeding duration was not associated with Wide Range Assessment
of Memory and Learning scores. Beneficial effects of breastfeeding on the Wide Range
Assessment of Visual Motor Abilities at age 3 years seemed greater for women who
consumed 2 or more servings of fish per week (0.24; 0.00-0.47 points per month breastfed)
compared with less than 2 servings of fish per week (−0.01; −0.22 to 0.20 points per month
breastfed) (P = .16 for interaction).

CONCLUSIONS AND RELEVANCE Our results support a causal relationship of breastfeeding
duration with receptive language and verbal and nonverbal intelligence later in life.

JAMA Pediatr. 2013;167(9):836-844. doi:10.1001/jamapediatrics.2013.45

Published online July 29, 2013.

Editorial page 79

Author Affiliations: Division of
Newborn Medicine, Boston Children’s
Hospital, Harvard Medical School,
Boston, Massachusetts (Belfort);
Department of Population Medicine,
Harvard Medical School and Harvard
Pilgrim Health Care Institute, Boston,
Massachusetts (Rifas-Shiman,
Kleinman, Guthrie, Taveras, Gillman,
Oken); Department of Neurology,
Boston Children’s Hospital, Harvard
Medical School, Boston,
Massachusetts (Bellinger);
Departments of Epidemiology and
Nutrition, Harvard School of Public
Health, Boston, Massachusetts
(Gillman).

Corresponding Author: Mandy B.
Belfort, MD, MPH, Division of
Newborn Medicine, Boston Children’s
Hospital, Harvard Medical School,
Hunnewell Room 438, 30

Longwood Ave, Boston, MA 02115
(mandy.belfort@childrens.harvard
.edu).

Research

Original Investigation

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S trong evidence supports the relationship between breast-
feeding and health benefits in infancy, including pre-
vention of gastrointestinal tract infections and otitis

media.1 The extent to which breastfeeding leads to better cog-
nitive development is less certain. While observational
studies1-4 have reported positive associations of breastfeed-
ing with later intelligence, breastfeeding is strongly related to
determinants of child intelligence, such as maternal intelli-
gence, and developmental stimulation received by the child;
residual confounding by such shared determinants may have
led observational studies1,2,5 to overestimate the effect of
breastfeeding on child intelligence. Another limitation of prior
investigations is the classification of infant feeding as ever
vs never breastfed.4 Failure to account for partial vs exclu-
sive breastfeeding or breastfeeding duration could lead to
underestimation of the true effect of breastfeeding on child
intelligence. Detailed data regarding breastfeeding exposure
and adequate control for confounding factors are necessary
for valid estimates of the relationship between breastfeed-
ing and later intelligence, but no study to date has fulfilled
these requirements.

Nutrients in breast milk, such as n-3 fatty acid docosa-
hexaenoic acid (DHA), may benefit the developing brain.
A major determinant of breast milk DHA content is
the mother’s diet,6 and fish is a rich source of DHA. In
pregnancy, greater maternal fish intake (particularly fish
low in mercury contamination) is associated with better
childhood cognitive outcomes,7 but the extent to which
maternal fish intake during lactation accounts for the
relationship between breastfeeding and cognition has not
been reported. The aims of our study were 2-fold: (1) to
examine relationships of breastfeeding duration and ex-
clusivity with child cognition at ages 3 and 7 years and (2) to
evaluate the extent to which maternal fish intake during
lactation modifies associations of infant feeding with later
cognition.

Methods
Participants
We studied participants in Project Viva, a prospective, longi-
tudinal cohort study designed to examine prenatal factors
in relation to pregnancy and child health. From April 22,
1999, to July 31, 2002, Project Viva enrolled pregnant
women attending prenatal care at 8 obstetrical offices of a
multispecialty group practice in eastern Massachusetts.
Exclusion criteria included multiple gestation, inability to
answer questions in English, gestational age of at least 2

weeks at the initial prenatal care appointment, and plans to
move away from the area before delivery. Recruitment and
follow-up details at birth,8 at 6 months,9 and at 3 years10

have been reported. Follow-up data collection at age 7 years
was completed in December 2010. Human investigation
committees of the Harvard Pilgrim Health Care Institute,
Brigham and Women’s Hospital, and Beth Israel Deaconess
Medical Center approved the study, and mothers of all par-
ticipating children gave written informed consent.

Of 2128 women who delivered a live infant, we excluded
45 children born at a gestational age of less than 34 weeks, 325
children who were missing breastfeeding status at age 6 months
and breastfeeding duration at age 12 months, and 446 chil-
dren who were missing cognitive measures at ages 3 and 7 years.
Therefore, our sample for this analysis comprised 1312 Proj-
ect Viva mothers and children (1224 at age 3 years and 1037 at
age 7 years).

Measurements
Breastfeeding
When the participating child was ages 6 and 12 months, we
asked the mother the questions listed in Table 1. To deter-
mine breastfeeding exclusivity at ages 6 and 12 months, we
asked detailed questions about the age at which solid foods
and non–breast milk liquids were introduced.

Cognition
When children were age 3 years, trained research staff
administered the Peabody Picture Vocabulary Test–Third
Edition (PPVT-III),11 a test of receptive language correlated
(Pearson R = 0.90) with intelligence tests, such as the
Wechsler Intelligence Scale for Children III. We also admin-
istered the Wide Range Assessment of Visual Motor Abilities
(WRAVMA)12 pegboard (fine motor), matching (visual spa-
tial), and drawing (visual motor) subtests. Subtest scores are
reported individually and combined as a visual motor com-
posite score.

At age 7 years, we administered the WRAVMA drawing sub-
test and the Kaufman Brief Intelligence Test–Second Edition
(KBIT-II), which measures verbal and nonverbal intelligen

and is correlated (Pearson R = 0.89) with the Wechsler Intel-
ligence Scale for Children III.13 In addition, we assessed memory
and learning with the Wide Range Assessment of Memory and
Learning (WRAML)14 design memory and picture memory
tests. Scores were summed to yield a visual memory com-
bined score.

Table 1. Questions About Breastfeeding at Ages 6 and 12 Months

Question About Breastfeeding
At Age 6 mo

For all infants

(1) Have you ever breastfed your baby? By breastfeeding, we mean that
you have put your baby to your breast, whether or not your baby actually
received breast milk, or that you have fed your baby your breast milk.
(2) Are you now feeding your baby any infant formula?

(3) Are you now feeding your baby any breast milk?

For weaned infants

How old was your baby when you stopped breastfeeding?

At Age 12 mo

For all infants

Have you ever breastfed your child?

Are you still breastfeeding at all?

For weaned infants

How old was your child when you stopped breastfeeding?

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Study staff administering cognitive tests were unaware of
the children’s breastfeeding status. The PPVT-III, WRAVMA,
and KBIT-II are scaled to a mean (SD) score of 100 (15).

Covariates
We collected data from mothers regarding parental and child
demographic, social, economic, and health information
through self-administered questionnaires and interviews in
pregnancy and shortly after delivery.15 At 6 months’ post par-
tum, we administered a brief, validated food frequency
questionnaire,16 including questions about the mother’s mean
weekly fish intake (canned tuna fish, shellfish, and dark meat
fish [eg, mackerel, salmon, sardines, bluefish, or swordfish],
as well as other fish [eg, cod, haddock, or halibut]) since the
infant’s birth. To measure maternal intelligence, we adminis-
tered to mothers the PPVT-III when the child was age 3 years
and the KBIT-II when the child was age 7 years. We also ad-
ministered the Home Observation Measurement of the Envi-
ronment short form (HOME-SF),17 which measures cognitive
stimulation and emotional support in the child’s environ-
ment. Higher scores (range, 0-22) indicate more favorable en-
vironments.

Data Analysis
Our main exposures were the following: (1) duration of any
breastfeeding in months; (2) duration of exclusive breastfeed-
ing in months, defined as feeding breast milk but no solid foods
or non–breast milk liquids (except water) to age 6 months; and
(3) breastfeeding status at age 6 months, categorized as “for-
mula only, never breast fed,” “formula only, weaned,” “mixed
formula and breast milk,” and “breast milk only, no formula.”
Our outcome measures were the PPVT-III and WRAVMA scores
at age 3 years and the KBIT-II, WRAVMA, and WRAML scores
at age 7 years. To examine the effect of potential confounders
on estimated relationships of breastfeeding measures with cog-
nitive outcome measures, we adjusted for 4 models in linear
regression. Model 0 adjusted for child age and sex. Model 1 ad-
justed for covariates in model 0 plus gestational age and birth
weight z score.18 Model 2 adjusted for covariates in model 1 plus
child race/ethnicity and maternal age, parity, smoking status,
depression at 6 months’ post partum, and employment and
child care at age 6 months, as well as primary language, an-
nual household income, and parental educational level and
marital status. Model 3 adjusted for covariates in model 2 plus
HOME-SF score. Model 4 adjusted for covariates in model 3 plus
maternal PPVT-III or KBIT-II score.

To compare our results with those of other studies, we es-
timated the difference in cognitive test scores between chil-
dren ever vs never breastfed. To examine the extent to which
maternal fish intake modified relationships of breastfeeding
with outcome measures, we stratified by fish intake (<2 vs ≥2 servings per week) and calculated the P value for an interac- tion term (breastfeeding duration × fish intake) in linear re- gression.

All covariates were not observed in all participants. Using
only individuals with all data observed would have resulted
in a smaller sample size, with most excluded participants miss-
ing only 1 or 2 values, leading to lost information and possibly

a selected subset. Therefore, we used multiple imputation to
generate several plausible values for each missing value.19 To
generate imputation data sets, we used a set of variables cho-
sen from the thousands available in Project Viva to reflect
demographic and other factors that we deemed plausibly re-
lated to potential missingness mechanisms and to the expo-
sures and outcome measures. A “completed” data set in-
cludes the observed data and an imputed value for each missing
value. The analysis was replicated across completed data sets
and then combined in a structured fashion that accurately re-
flects the true amount of information in the observed data.
This method assumes that the exposures and outcome mea-
sures are missing completely at random given the observed
variables and the imputed covariates. This is a reduced as-
sumption relative to that made in studies that use only com-
plete cases. Using a statistical program (Proc MI ANALYZE in
SAS, version 9.3; SAS Institute, Inc), we generated 50 complete
data sets and combined multivariable modeling results for all
2128 participants in the Project Viva cohort. For this analysis,
we excluded participants born at a gestational age of less than
34 weeks and those missing observed exposure or outcome
data.

Results
Table 2 summarizes characteristics of participants included at
ages 3 and 7 years and characteristics of the excluded partici-
pants. Compared with those included in the analysis, moth-
ers of excluded participants were less educated, had lower an-
nual household income, were more likely to be of nonwhite
race/ethnicity, and breastfed for a shorter duration. For 122

participants included at age 3 years, the mean duration of any
breastfeeding was 6.4 months and of exclusive breastfeeding
was 2.4 months; values were similar for participants in-
cluded at age 7 years. The PPVT-III mean score at age 3 years
was 103.7, and the KBIT-II verbal mean score at age 7 years was
112.5.

Table 3 summarizes the effect of covariate adjustment on
estimated relationships between breastfeeding duration and
child cognitive outcomes. Adjusting for child age and sex
(model 0), longer breastfeeding duration was associated with
higher PPVT-III score at age 3 years (0.58; 95% CI, 0.40-0.76
points per month breastfed). This relationship was similar with
additional adjustment for fetal growth and gestational age
(model 1) and attenuated with adjustment for demographic
variables (model 2) and HOME-SF score (model 3). With fur-
ther adjustment for maternal IQ (model 4), the association di-
minished to 0.21 (95% CI, 0.03-0.38) points per month breast-
fed. We observed a similar pattern of attenuation for the KBIT-II
verbal and nonverbal scores at age 7 years.

In Table 4, we give fully adjusted associations of any and
exclusive breastfeeding with all cognitive test scores at ages

and 7 years. Associations of breastfeeding duration (any and
exclusive) with the PPVT-III score and the KBIT-II verbal and
nonverbal scores were positive, and 95% CIs excluded 0. The
Figure shows the adjusted KBIT-II scores at age 7 years by cat-
egory of any breastfeeding duration (<1, 1-3, 4-6, 7-9, 10-11, and

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Table 2. Included and Excluded Project Viva Mothers and Children

Variable

Included at Age 3
y

(n = 1224)
Included at Age 7 y

(n = 1037)
Excluded at Ages 3 and 7 ya

(n = 771)

Mother

Age, mean (SE), y 32.5 (0.1) 32.3 (0.2) 31.0 (0.2)

PPVT-III score, mean (SE) 106.0 (0.4) 105.4 (0.5) 100.8 (0.8)

KBIT-II score, mean (SE) 107.9 (0.5) 107.2 (0.5) 102.5 (0.7)

≥2 Servings of fish per wk, % 55.0 52.8 50.

Parity, %

0 47.5 47.3 47.6

1 36.3 36.4 35.4

≥2 16.2 16.4 17.0

Smoking status, %

Never 68.8 70.1 64.5

Former 21.0 20.1 17.4

During pregnancy 10.2 9.8 18.1

Depression at 6 mo post partum, % 8.8 9.1 11.0

Educational level, %

≤High school diploma 7.2 8.6 18.8

Some college 20.2 21.3 26.9

Bachelor’s degree 37.7 34.9 32.7

Graduate degree 34.9 35.2 21.6

Employment at 6 mo post partum, %

Employed 66.0 66.7 56.0

Employed, on maternity leave 6.0 6.8 6.2

Not employed, looking 4.6 5.3 10.1

Not employed, not looking 23.3 21.3 27.7

Child

Gestational age, mean (SE), wk 39.6 (0.0) 39.7 (0.0) 39.6 (0.1)

Birth weight, mean (SE), kg 3.5 (0.0) 3.5 (0.0) 3.5 (0.0)

Birth weight for gestational age z
score, mean (SE)

0.22 (0.03) 0.20 (0.00) 0.14 (0.04)

Female sex, % 50.4 50.5 47.7

Race/ethnicity, %

Asian 2.7 3.0 5.8

Black 11.9 15.1 21.0

Hispanic 3.5 3.7 8.0

White 70.1 66.1 55.4

Other 11.8 12.2 9.8

Primary English speaker, % 96.2 98.7 92.7

Child care at age 6 mo, %

Center 16.8 17.2 17.4

Other home 26.1 27.3 24.8

At own home 14.3 13.6 14.9

None 42.8 42.0 43.0

Breastfeeding status at age 6 mo, %

Formula only, never breastfed 10.6 10.1 15.0

Formula only, weaned 34.7 35.1 46.3

Mixed formula and breast milk 26.4 26.8 19.5

Breast milk only, no formula 28.2 28.0 19.2

(continued)

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≥12 months). Associations of breastfeeding duration with
WRAVMA scores were null (with narrow 95% CIs).

Estimated cognitive test mean score differences accord-
ing to breastfeeding status at age 6 months are given in Table 5.
Compared with children fed breast milk only, the PPVT-III score
at age 3 years was approximately 3 points lower for children
never breastfed and approximately 2 points lower for weaned

children and those receiving mixed feedings (P = .01 for trend).
We found a similar trend for the KBIT-II verbal and nonverbal
scores at age 7 years but observed no appreciable trend for the
WRAVMA or WRAML scores.

Compared with children who were never breastfed, the
fully adjusted PPVT-III score at age 3 years was 1.45 (95% CI,
−0.98 to 3.87) points higher for children who were ever breast-

Table 3. Effect of Covariate Adjustment on Estimated Associations of Duration of Any Breastfeeding With Child Cognitiona

Model

Points (95% CI) per Month Breastfed

At Age 3 y

(n = 1224)

At Age 7 y

(n = 1037)

PPVT-III Score KBIT-II Verbal Score KBIT-II Nonverbal

Score

0, Child age and sex 0.58 (0.40 to 0.76) 0.96 (0.77 to 1.14) 0.65 (0.43 to 0.87)

1, Model 0 plus fetal growth and gestational age 0.57 (0.39 to 0.75) 0.95 (0.76 to 1.14) 0.64 (0.42 to 0.86)

2, Model 1 plus demographic variablesb 0.29 (0.12 to 0.47) 0.46 (0.28 to 0.65) 0.38 (0.13 to 0.62)

3, Model 2 plus HOME-SF score 0.29 (0.11 to 0.46) 0.46 (0.27 to 0.64) 0.38 (0.13 to 0.62)

4, Model 3 plus maternal IQ 0.21 (0.03 to 0.38) 0.35 (0.16 to 0.53) 0.29 (0.05 to 0.54)

b Child race/ethnicity and maternal age, parity, smoking status, depression,
employment, and child care at 6 months’ post partum, as well as parental
educational level and marital status, annual household income, and primary
language.

Table 2. Included and Excluded Project Viva Mothers and Children (continued)

Variable

Included at Age 3
y

(n = 1224)
Included at Age 7 y

(n = 1037)
Excluded at Ages 3 and 7 ya

(n = 771)

Duration of breastfeeding, mean
(SE), mo

Exclusive to age 6 mo 2.4 (0.1) 2.4 (0.1) 1.9 (0.1)

Any to age 12 mo 6.4 (0.1) 6.5 (0.1) 4.9 (0.2)

Cognitive test score, mean (SE)

At age 3 y

PPVT-III 103.7 (0.43) NA NA

WRAVMA total 101.8 (0.33) NA NA

At age 7 y

KBIT-II verbal NA 112.5 (0.5) NA

KBIT-II nonverbal NA 106.5 (0.5) NA

WRAVMA drawing NA 92.2 (0.5) NA

WRAML visual memory NA 16.9 (0.1) NA

Family or Household

HOME-SF score, mean (SE) 18.4 (0.1) 18.4 (0.1) NA

Annual household income during
first trimester, %

<$40 000 14.3 16.2 23.2

$40 001-$70 000 22.3 21.2 26.4

>$70 000 63.4 62.6 50.4

Married or cohabitating during first
trimester, %

93.6 92.4 89.3

Mother’s Partner

Educational level, %

≤High school diploma 13.3 14.2 22.1

Some college 19.8 20.5 24.7

Bachelor’s degree 36.5 35.7 30.0

Graduate degree 30.4 29.6 23.3

Abbreviations: HOME-SF, Home
Observation Measurement of the
Environment short form; KBIT-II,
Kaufman Brief Intelligence
Test–Second Edition; NA, not
applicable; PPVT-III, Peabody Picture
Vocabulary Test–Third Edition;
WRAML, Wide Range Assessment of
Memory and Learning; WRAVMA,
Wide Range Assessment of Visual
Motor Abilities.
a Excluded because of missing

exposure or outcome data.

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fed, and the KBIT-II verbal score at age 7 years was 3.75 (1.17-
6.33) points higher. The WRAVMA and WRAML scores were not
statistically different (data not shown).

Stratifying by maternal postpartum fish intake (<2 vs ≥2 servings per week), the relationship between breastfeeding du- ration and the WRAVMA score at age 3 years seemed stronger in children of women with higher vs lower fish intake (Table 6), but the interaction was not statistically significant (P = .16 for interaction). For other cognitive outcomes, associations with breastfeeding duration were not appreciably stronger among children of women who consumed more fish.

Discussion
We found that longer duration of breastfeeding and greater
exclusivity of breastfeeding were associated with better
receptive language at age 3 years and with higher verbal and
nonverbal IQ at age 7 years. At age 7 years, the effect size of
0.35 verbal IQ points per month of any breastfeeding trans-
lates to 4.2 points, or almost one-third of an SD during 12
months, whereas the effect size of 0.80 verbal IQ points per
month of exclusive breastfeeding translates to almost 5
points over 6 months. Effects were similar in direction but
somewhat weaker in magnitude for nonverbal IQ and recep-
tive language at age 3 years. We found no important main
association of breastfeeding with visual motor skills or
visual memory.

While numerous investigations have demonstrated asso-
ciations of breastfeeding with later cognition, some studies1,4,5

have had methodological flaws. In particular, adequate con-
trol for confounding factors is critical because breastfeeding
and child cognition share many determinants, including ma-
ternal characteristics and environmental factors. A 2007
meta-analysis1 identified maternal intelligence and the home
environment as key confounders that are frequently over-
looked and found only 1 prior study5 with appropriate adjust-
ment, an analysis of data from the US National Longitudinal
Survey of Youth (NSLY) in which the association of breastfeed-
ing (ever vs never) with achievement scores at ages 5 to 14 years
was attenuated from 4.7 to 1.3 points after adjustment for ma-
ternal intelligence and diminished to only 0.5 points after ad-
justment for sociodemographic and other variables, includ-
ing the HOME-SF score. We also adjusted for maternal
intelligence and the HOME-SF score, as well as numerous other
potential confounders, and nevertheless found a substan-
tially stronger association (3.75 points) of ever vs never breast-
fed with verbal IQ at age 7 years.

It is possible that differences in the degree of breastfeed-
ing exclusivity explain why we observed a stronger associa-
tion of breastfeeding with cognition than was seen in the
NSLY.5 By classifying breastfeeding as ever vs never, the NSLY
may have included in their breastfed group a substantial
number of infants who received formula and breast milk,
biasing results toward the null, but the authors did not report
the degree of mixed feedings. Differences in breastfeeding
duration may also explain our discrepant results. In a second-
ary analysis, the NSLY found that the achievement scores of
children breastfed for at least 29 weeks were 1.5 points higher
than those of children never breastfed (P = .01), but the
authors considered their data about breastfeeding duration
“less reliable” than data about whether a child was ever

Figure. Differences in Kaufman Brief Intelligence Test–Second Edition
Verbal Scores at Age 7 Years According to Duration of Any
Breastfeeding, With Linear Trend Line

1-3 4-6 7-9 10-11 ≥12

Ve
rb

al
IQ

D
iff

er
en

Duration of Any Breastfeeding, mo

Estimates are adjusted for child age, sex, fetal growth, gestational age,
race/ethnicity, and primary language and for maternal age, parity, smoking
status, IQ, depression, employment, and child care at 6 months’ post partum, as
well as for parental education level, annual household income, and Home
Observation Measurement of the Environment short form score.

Table 4. Adjusted Associations of Duration of Breastfeeding With
Cognitive Test Scoresa

Score

Points (95% CI) per Month Breastfed
Any Breastfeeding

to Age 12 mo
Exclusive Breastfeeding

to Age 6 mob

At Age 3 y

PPVT-III 0.21 (0.03 to 0.38) 0.50 (0.11 to 0.89)

WRAVMA drawing 0.01 (−0.15 to 0.16) −0.12 (−0.47 to 0.22)

WRAVMA pegboard 0.09 (−0.06 to 0.24) −0.03 (−0.37 to 0.31)

WRAVMA matching 0.09 (−0.10 to 0.27) 0.00 (−0.42 to 0.41)

WRAVMA total 0.08 (−0.07 to 0.23) −0.07 (−0.40 to 0.27)

At Age 7 y

KBIT-II verbal 0.35 (0.16 to 0.53) 0.80 (0.38 to 1.22)

KBIT-II nonverbal 0.29 (0.05 to 0.54) 0.58 (0.01 to 1.14)

WRAVMA drawing −0.08 (−0.33 to 0.18) −0.05 (−0.62 to 0.53)

WRAML visual
memory

0.04 (−0.02 to 0.11) 0.12 (−0.03 to 0.27)

Abbreviations: HOME-SF, Home Observation Measurement of the Environment
short form; KBIT-II, Kaufman Brief Intelligence Test–Second Edition; PPVT-III,
Peabody Picture Vocabulary Test–Third Edition; WRAML, Wide Range
Assessment of Memory and Learning; WRAVMA, Wide Range Assessment of
Visual Motor Abilities.

a Estimates are adjusted for child age, sex, fetal growth, gestational age,

race/ethnicity, and primary language and for maternal age, parity, smoking
status, IQ, depression, employment, and child care at 6 months’ post partum,

as well as for parental educational level, annual household income, and
HOME-SF score.

b No solid foods or non–breast milk liquids (except water).

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breastfed. Finally, variable outcome measures (achievement
test score in the NSLY vs IQ in our study) may explain our dif-
ferent results.

We identified 4 additional observational studies20-23 that
adjusted for maternal intelligence and the HOME-SF score.
While we found a modest association of breastfeeding with
verbal intelligence at age 3 years, neither of the other 2 pre-
school studies found an important association with cogni-
tive outcomes (McCarthy General Cognitive Index21,22 and
PPVT-Revised22 at age 4 years). Of the studies reporting
school-age outcomes, one study21 found a 1.3-point (95% CI,
−2.3 to 4.9) advantage of ever vs never breastfeeding on the
Wechsler Full-Scale IQ at age 7 years; another study23 found
a 0.7-point (0.2-1.3) advantage on the same outcome at age 11
years; and the other study22 found no association with ver-
bal or performance IQ at age 11 years (effect estimate not

reported). All those effect estimates are smaller than ours,
but none of the studies accounted for breastfeeding duration
or exclusivity.

Studies of cohorts with different confounding patterns are
also informative. Brion et al24 analyzed associations of breast-
feeding duration with IQ at age 8 years in 2 cohorts. In one co-
hort (the British Avon Longitudinal Study of Parents and Chil-
dren), breastfeeding duration and child IQ were strongly
predicted by measures of socioeconomic position, whereas in
the other cohort (Pelotas, Brazil) child IQ was predicted by so-
cioeconomic factors, but breastfeeding duration was not. In
both cohorts, child IQ was strongly associated with breast-
feeding duration, suggesting that confounding alone did not
explain the relationship.

The results of our study are also consistent with a large clus-
ter randomized trial25 of breastfeeding promotion in which ver-

Table 5. Adjusted Cognitive Test Score Differences at Ages 3 and 7 Years According to Breastfeeding Status at Age 6 Monthsa

Score

Difference in Points (95% CI)

P Value for TrenddNever Breastfed Weaned Mixed Feedingsb Breast Milk Onlyc

At Age 3 y

PPVT-III −3.17 (−5.92 to −0.41) −2.26 (−4.22 to −0.29) −2.27 (−4.24 to −0.30) 0.00 [Reference] .01

WRAVMA drawing −0.63 (−3.03 to 1.78) −0.01 (−1.74 to 1.72) −0.52 (−2.27 to 1.22) 0.00 [Reference] .80

WRAVMA pegboard −1.96 (−4.31 to 0.39) −0.36 (−2.05 to 1.34) 0.04 (−1.66 to 1.74) 0.00 [Reference] .18

WRAVMA matching −1.93 (−4.82 to 0.96) −0.62 (−2.65 to 1.41) −1.13 (−3.21 to 0.96) 0.00 [Reference] .29

WRAVMA total −2.04 (−4.39 to 0.30) −0.47 (−2.13 to 1.19) −0.75 (−2.42 to 0.93) 0.00 [Reference] .19

At Age 7 y

KBIT-II verbal −5.59 (−8.52 to −2.67) −2.96 (−5.05 to −0.88) −1.40 (−3.49 to 0.68) 0.00 [Reference] <.001

KBIT-II nonverbal −2.71 (−6.62 to 1.21) −3.11 (−5.89 to −0.33) −1.33 (−4.08 to 1.43) 0.00 [Reference] .04

WRAVMA drawing 0.47 (−3.62 to 4.55) −0.14 (−3.03 to 2.76) −0.73 (−3.61 to 2.15) 0.00 [Reference] .87

WRAML visual memory −0.67 (−1.72 to 0.39) −0.30 (−1.06 to 0.45) 0.39 (−0.36 to 1.14) 0.00 [Reference] .15

race/ethnicity, and primary language and for maternal age, parity, smoking
status, IQ, depression, employment, and child care at 6 months’ post partum,

as well as for parental educational level, annual household income, and
HOME-SF score.

b Breast milk and formula.
c No formula.
d P values are calculated in linear regression with breastfeeding category as a

continuous exposure variable (1 indicates never breastfed; 2, weaned; 3, mixed
feedings; and 4, breast milk only).

Table 6. Adjusted Associations of Duration of Breastfeeding With Cognitive Test Scores at Ages 3 and 7 Years by Postpartum Maternal Fish Intakea

Score

Points (95% CI) per Month Breastfed P Value for
Interaction<2 Servings of Fish per Week ≥2 Servings of Fish per Week

At Age 3 y

PPVT-III 0.10 (−0.15 to 0.35) 0.30 (0.03 to 0.58) .22

WRAVMA total −0.01 (−0.22 to 0.20) 0.24 (0.00 to 0.47) .16

At Age 7 y

KBIT-II verbal 0.31 (0.06 to 0.56) 0.35 (0.05 to 0.65) .82

KBIT-II nonverbal 0.36 (0.02 to 0.69) 0.15 (−0.25 to 0.56) .95

WRAVMA total −0.04 (−0.40 to 0.32) −0.06 (−0.47 to 0.35) .92

WRAML 0.06 (−0.03 to 0.16) 0.04 (−0.06 to 0.14) .75

a Estimates are adjusted for child age, sex, fetal growth, gestational age,
race/ethnicity, and primary language and for maternal age, parity, smoking
status, IQ, depression, employment, and child care at 6 months’ post partum,
as well as for parental educational level, annual household income, and
HOME-SF score.

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bal IQ at age 6.5 years was 7.5 points (one-half of an SD) higher
in the breastfeeding promotion group. By design, that study
minimized confounding by measured and unmeasured fac-
tors; however, nonblinding of clinicians assessing the cogni-
tive outcomes to participant breastfeeding status suggests the
potential for bias. Together, the results of the well-controlled
observational studies20-23 (including ours), the analysis of co-
horts without social patterning of breastfeeding (eg, in the Pelo-
tas cohort),24 and the large randomized trial25 suggest that con-
founding does not account fully for the observed association
of breastfeeding with later cognition.

In analyses stratified by fish intake, the beneficial effects
of breastfeeding on visual motor ability at age 3 years seemed
greater for women who consumed 2 or more servings com-
pared with less than 2 servings per week, although the inter-
action was not statistically significant. This observation is con-
sistent with the hypothesis that 1 or more nutrients in fish
transfer to breast milk and account for some of the observed
beneficial effect and is relevant to optimizing the maternal diet
during lactation. Docosahexaenoic acid is incorporated in large
amounts into cell membranes of the developing retina and
brain. Its content in breast milk is variable26 and depends on
DHA sources in the maternal diet,6,27 including fish; infant DHA
status in turn depends on the DHA content of ingested breast
milk.27 Randomized trials of DHA supplementation during lac-
tation have found beneficial effects of DHA on early motor
skills28 and sustained attention29 but not visual motor func-
tion or general cognition.28,30 Our observation may be ex-
plained by DHA or nutrients in fish other than DHA. It may also
be a chance finding.

Strengths of our study include a prospective design, de-
tailed contemporaneous measurement of duration and exclu-
sivity of breastfeeding, and measurement of numerous poten-
tial confounding variables, including the home environment and
maternal IQ. As in all observational studies, confounding by un-
measured factors is possible and may have led us to overesti-
mate the true effect of breastfeeding, although our results are
consistent with data from a randomized trial25 of breastfeed-
ing promotion that eliminates confounding by design. We mea-
sured cognition at school age, which tends to be stable through
adulthood31 compared with measurement in preschool or ear-
lier. The elevated socioeconomic status and high breastfeed-
ing rate of our cohort may limit generalizability of the study find-
ings. In addition, we followed up only a subset of the original
Project Viva cohort to ages 3 and 7 years. The children we ob-
served tended to be of higher socioeconomic status and were
less likely to be of minority race/ethnicity than the children we
did not follow up, which could have led to overestimates if the
effect of breastfeeding on cognition was much weaker or in the
opposite direction in those who dropped out, situations we find
unlikely. Finally, for the statistically significant associations of
breastfeeding with later cognition, 95% CIs were narrow and ex-
clude a null result, but the lower confidence limits include val-
ues with little clinical importance.

In summary, our results support a causal relationship of
breastfeeding in infancy with receptive language at age 3 and
with verbal and nonverbal IQ at school age. These findings sup-
port national and international recommendations to pro-
mote exclusive breastfeeding through age 6 months and con-
tinuation of breastfeeding through at least age 1 year.

ARTICLE INFORMATION

Accepted for Publication: February 6, 2013.

Published Online: July 29, 2013.
doi:10.1001/jamapediatrics.2013.455.

Author Contributions: Study concept and design:
Belfort, Kleinman, Gillman, Oken.
Acquisition of data: Bellinger, Gillman, Oken.
Analysis and interpretation of data: Belfort,
Rifas-Shiman, Kleinman, Guthrie, Bellinger, Taveras,
Oken.
Drafting of the manuscript: Belfort.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Belfort, Rifas-Shiman, Kleinman,
Guthrie.
Obtained funding: Belfort, Gillman, Oken.
Administrative, technical, and material support:
Gillman.
Study supervision: Bellinger, Taveras, Gillman, Oken.

Conflict of Interest Disclosures: None.

Funding/Support: This work was supported by
grants K23 DK083817 (Dr Belfort), K24 HL68041
(Dr Gillman), K24 HD069408 (Dr Oken), R01
ES016314, R01 HD34568, and R01 HL64925 from
the National Institutes of Health.

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7. Oken E, Radesky JS, Wright RO, et al. Maternal
fish intake during pregnancy, blood mercury levels,
and child cognition at age 3 years in a US cohort.
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8. Oken E, Kleinman KP, Olsen SF, Rich-Edwards
JW, Gillman MW. Associations of seafood and
elongated n-3 fatty acid intake with fetal growth
and length of gestation: results from a US

pregnancy cohort. Am J Epidemiol.
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9. Gillman MW, Rifas-Shiman SL, Kleinman KP,
Rich-Edwards JW, Lipshultz SE. Maternal calcium
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10. Taveras EM, Rifas-Shiman SL, Scanlon KS,
Grummer-Strawn LM, Sherry B, Gillman MW. To
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11. Williams KT, Wang J-J. Technical References to
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DE: Wide Range Inc; 1995.

13. Grados JJ, Russo-Garcia KA. Comparison of the
Kaufman Brief Intelligence Test and the Wechsler
Intelligence Scale for Children–Third Edition in
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youth. J Clin Psychol. 1999;55(9):1063-1071.

14. Adams W, Sheslow D. Wide Range Assessment
of Memory and Learning Administration and
Technical Manual. 2nd ed. Lutz, FL: Psychological
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SL, Lieberman ES, Kleinman KP, Lipshultz SE.

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Developed by Ron Lally and Cathy Tsao. © 2004, WestEd, The Program for Infant/Toddler Care.
This document may be reproduced for educational purposes.

Definition
The concept of continuity of care refers to the policy of assigning a primary caregiver to an
infant at the time of enrollment in a child care program and continuing this relationship until the
child is at least three years old.

With continuity, the infant is not moved to a new group; either the entire group moves with the
caregiver to another space more appropriate for older infants, or the caregiver modifies the
environment to meet the children’s changing needs. The most important relationship to
continue is the one between the child and the primary caregiver, but promoting long-term
relationships with other caregivers and with other children in the group is also important.

Foundation: Theory and Research
In attachment theory, stability and consistency of caregivers are seen as important factors in the
development and maintenance of secure attachment relationships (Bowlby, 1973). Children
take a significant amount of time to form attachments to caregivers, so they are less likely to
form attachments if frequent caregiver changes occur. More frequent changes in primary
caregiver have been associated with negative child outcomes, including withdrawing behaviors
and higher levels of aggression as preschoolers (Howes & Hamilton, 1993).

On the other hand, time with a high-ability teacher has been positively associated with security
of attachment in infant day care (Raikes, 1993). When infants are able to develop a relationship
with a teacher over time, the infant-teacher relationship becomes more defined and predictable,
creating a secure base for the infant. Raikes (1993) found that attachment security increased
as children spent more time with their primary caregivers, and that 91% of infants who had been
with their teacher for over one year were categorized as securely attached. These results are
consistent with attachment theory, which suggests that time in a relationship is required in order
for secure attachments to develop. However, the theory does not imply that time with an
insensitive or non-responsive teacher would also promote security in infant-teacher attachment;
in fact, such an arrangement may lead to the infant’s developing an insecure relationship with
the teacher. The quality with which the teacher interacts with the child is key.

Context
There is a clear link between child care quality and child outcomes, where child care quality is
defined by either structural variables, which can be regulated, such as group size and continuity
of care; or process variables, which require judgment and interpretation, and are difficult or
impossible to regulate, such as sensitive and responsive caregiving (Howes, Phillips, &
Whitebook, 1992). Structural variables are thought to influence process variables, and
researchers (Raikes, 1993) have conceptualized the infant-teacher relationship as a mediator
between child care quality and child outcomes.

Continuity of Care

Research and theory have established the necessity of intimate caregiving relationships for
laying a foundation of trust, providing predictability, regulating attention, and creating interest for
infants. Raikes (1993) hypothesizes that “time with teacher”—the length of time a high-ability
teacher cares for an infant—is an indicator of quality for the infant-teacher relationship.

Structural Variables
In the context of the PITC philosophy’s six essential policies1, continuity supports the secure,
warm relationships infants and toddlers need in order to thrive. Continuity begins with
assignment of a primary caregiver who develops a close relationship with the child and the
family and is primarily responsible for the child’s care. These relationships—and all
relationships in the setting—are supported by the organization of caregivers and children into
small groups. These three program policies—primary care, small groups, and continuity—
promote feelings of security and predictability for infants and toddlers in group care. These
policies work best together, but any one of them will improve the quality of care.

Process Variables
The ideal match is between program policies that support relationships and highly sensitive
teachers who implement those policies. In addition to the three policies described above, other
components of the PITC philosophy—responsive caregiving, culturally sensitive care and family
support, and attention to temperamental differences—contribute to the quality of interactions.
With a working knowledge of these components teachers become increasingly able to provide
appropriate infant care and family support.

Barriers
Among continuity, primary caregiving, and small groups, the concept of continuity is the most
likely to encounter resistance, in part because it is the newest idea. In a study of child care
centers across the United States, the practice of continuity of care was found to be rare (Cryer,
Hurwitz, & Wolery, 2000). While the infant’s need for close relationships is incontrovertible, the
idea that we can and should promote long-term relationships in infant/toddler programs
challenges us to new heights at a time when many programs are consumed with basic survival.
Teachers and administrators need support and information to help them in the process of
implementation of continuity of care and to ensure the entire staff believes in its role in the
development of relationships and healthy attachment. Without disregarding the real-life
concerns that programs face, we can strive to set the bar—rather than aim for the lowest
common denominator—by encouraging programs to take one step at a time and to move
steadily to the provision of continuity.

Structuring infant/toddler programs to promote long-term relationships often means reorganizing
the environment, staffing, training, admission policies—the very systems by which we staff,
enroll and care for children. It raises logistical questions that cannot be answered in the
abstract, e.g., safety regulations, subsidy requirements, age-related fee and reimbursement
schedules. Every program needs to find its own solutions to the arrangement of space and
equipment, the scheduling of children and caregivers, staffing ratios and group size, etc.

Ultimately, continuity of child care relationships—along with small groups and primary
caregiving assignments—benefit everyone in a program, promoting staff and family cooperation

1 PITC’s six essential policies are continuity, primary caregiving, small groups, individualized care,
cultural sensitivity, and inclusion of children with special needs.

and loyalty; creating a calmer, less stressful environment; and providing better opportunities for
the growth and development of adults as well as children.

References

Barnas, M.V., & Cummings, E.M. (1994). Caregiver stability and toddlers’ attachment-related

behavior towards caregivers in day care. Infant Behavior and Development, 17, 141 –
147.

Bowlby, J. (1973). Attachment and loss, Vol. 2: Separation. London: Basic Books.

Cryer, D., Hurwitz, S., & Wolery, M. (2000). Continuity of caregiver for infants and

toddlers in center-based child care: Report on a survey of center practices. Early
Childhood Research Quarterly, 15(4), 497 – 514.

Howes, C., & Hamilton, C.E. (1993). The changing experience of child care: Changes in

teachers and in teacher-child relationships and children’s social competence with peers.
Early Childhood Research Quarterly, 8, 15 – 32.

Howes, C., Phillips, D.A., & Whitebook, M. (1992). Thresholds of quality: Implications for the

social development of children in center-based child care. Child Development, 63, 449 –
460.

Raikes, H. (1993). Relationship duration infant care: Time with a high-ability teacher and infant-

teacher attachment. Early Childhood Research Quarterly, 8, 309 – 325.

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Clinical digest

NEW EVIDENCE ADDS TO
THE BREAST VERSUS
BOTTLE-FEEDING DEBATE
UK research compares temperaments
of babies fed by different methods

New mothers should be informed that it is
normal for breastfed babies to cry more and
appear less content than bottle-fed babies.

The Medical Research Council asked mothers
to assess the temperaments of their babies at
three months using a behaviour questionnaire.
Of the 316 babies, 137 were exclusively
breastfed, 88 were fed with formula milk and
91 were fed with a combination.

Overall, breast and mixed-fed babies were
rated by their mothers as having more
challenging temperaments. Compared to
formula-fed babies, breastfed babies showed
greater distress, and were less likely to smile,
laugh or vocalise. They were also slower to calm
down following distress or excitement.

Lead researcher Ken Ong, a paediatrician from
the Medical Research Council epidemiology unit
in Cambridge, says: ‘Bottle-fed babies may
appear more content, but research suggests
that they could gain weight too quickly.

‘Rather than being put off breastfeeding,
parents should have more realistic expectations

of normal infant
behaviour and should

receive better
support to cope
with difficult infant
behaviours if needed.’
The Department of

Health recommends
breastfeeding for the

first six months, but most
UK mothers switch to

bottle-feeding within
four months.
de Lauzon-Guillain
B et al (2012)

Breastfeeding
and infant
temperament
at age three
months.

PLoS One. doi:
10.1371/journal.
pone.0029326.

says more large studies are
needed to establish whether
red meat is a risk factor for
pancreatic cancer.

She adds: ‘Stopping smoking
is the best way to reduce your
chances of developing many
types of cancer – and other
diseases too.’
Larsson SC et al (2012) Red and
processed meat consumption
and risk of pancreatic cancer:
meta-analysis of prospective studies.
British Journal of Cancer.
doi: 10.1038/bjc.2011.585.

Bariatric surgery could have
more pronounced ‘benefits’
than standard lifestyle changes

Weight-loss surgery reduces the
risk of heart attacks and other
cardiovascular events, according
to research conducted as part
of the Swedish Obese Subjects
(SOS) study.

SOS is an ongoing study
of 2,010 participants who
underwent bariatric surgery
and a control group of 2,037
individuals who received usual
(non-surgical) care for their
obesity. Patients were aged
37 to 60, with a body mass
index of at least 34 in men and
at least 38 in women.

They were recruited between
1987 and 2001 and there was
a mean follow-up of 14.7 years.
Surgery patients underwent
vertical banded gastroplasty
(68.1 per cent), gastric bypass
(13.2 per cent) and banding
(18.7 per cent).

At two years follow-up, the
mean change in body weight in
surgery patients was a decrease
of 23 per cent; at ten years the
decrease was 16 per cent, at
20 years it was 18 per cent. In
the control group, there was no
change in body weight at two
years follow-up and only a 1 per
cent decrease at 15 and 20 years.

Swedish research establishes
link between eating processed
meat and pancreatic cancer

Eating processed meat increases
the risk of pancreatic cancer,
suggests a study that also found
red meat increases the risk of
the cancer in men.

Researchers at the Karolinksa
Institutet in Stockholm, Sweden,
conducted a meta-analysis of
11 studies involving 6,643
pancreatic cancer cases. They
found that for each 50 grams of
processed meat eaten each day –
equivalent to one sausage or two
rashers of bacon – there was a
19 per cent rise in the risk of
pancreatic cancer compared
to those who ate no meat.
Consuming 150g of processed
meat per day increased the risk
by 58 per cent.

The evidence for red meat
was inconclusive, with an
increase in risk for men, but
not for women. Men who ate
120g per day of red meat had
a 29 per cent increased risk of
pancreatic cancer compared
to those who ate no meat.

Study author Susanna Larsson
says that pancreatic cancer’s
poor survival rate means it is
important to understand the
factors that increase the risk
of the disease. ‘If diet affects
pancreatic cancer then this
could influence public health
campaigns to help reduce the
number of cases of this disease
developing in the first place.’

Cancer Research UK
information director Sara Hiom

NURSING STANDARD

A
LA

M
Y

C
K

PH
O

p16-17w22_CLINICAL DIGEST this one copy 5 30/01/2012 12:13 Page 16

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

PEDIATRIC REVIEW

The role of responsive feeding in overweight during
infancy and toddlerhood: a systematic

review

KI DiSantis1, EA Hodges2, SL Johnson3 and JO Fisher

1Center for Clinical Epidemiology and Biostatistics, School of Medicine, University of Pennsylvania, Philadelphia, PA, USA;
2Family Health Division, School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA;
3Department of Pediatrics, Section of Nutrition, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA and
4Department of Public Health, Temple University, Center for Obesity Research and Education, Philadelphia, PA, USA

A chronic mismatch of caregiver responsiveness to infant-feeding cues, such as feeding when the infant is not hungry, is
hypothesized to have a role in the development of overweight by impairing an infant’s response to internal states of hunger and
satiation. Although this concept of mismatch or discordance has long been acknowledged in scholarly writings, a systematic
assessment of the evidence supporting the role of discordant responsiveness during infant feeding in the early origins of
overweight is lacking. This review was undertaken to assess evidence for this hypothesized relationship between discordant
responsiveness in feeding and overweight in infancy and toddlerhood, framed within the larger social-environmental context of
the infant–caregiver dyad. A systematic method was used to extract articles from three databases of the medical, psychology
and nursing fields. The quality of evidence collected was assessed using Oxford University Centre for Evidence Based Medicine’s
level of evidence and through a narrative review. The systematic search resulted in only nine original research studies, which met
a priori inclusion/exclusion criteria. Several studies provide support for the conceptual model, but most were cross-sectional or
lower quality prospective studies. The need for consistent definitions, improved measures and longitudinal work is discussed.
In conclusion, this review reveals preliminary support for the proposed role of discordant responsiveness in infant/child overweight
and at the same time highlights the need for rigorous investigation of responsive feeding interactions in the first years of life.

International Journal of Obesity

(2011) 35, 480–492; doi:10.1038/ijo.2011.3; published online 22 March 2011

Keywords: infant; feeding behavior; responsiveness; appetite regulation; self-regulation; overweight

Introduction

Infancy is believed to be a sensitive period for the develop-

ment of energy intake regulation1 and overweight.2–6 In the

first 2 years of life, infants and toddlers are dependent on

their caregivers to provide adequate and appropriate nutri-

tion. For this reason, the potential influence of feeding

dynamics on overnutrition and the development of over-

weight is seemingly intuitive. Scholarly work on early life

origins of overweight, however, has largely ignored the

possible impacts of social and behavioral transactions on

infant feeding. We focus on one particular aspect of these

caregiver–infant transactions: responsive feeding. In this

review, we define responsiveness within the context of

overweight, as involving prompt, contingent and develop-

mentally appropriate responses to the infant’s hunger and

satiety cues. As the review will describe, the degree to which

feeding interactions are responsive is believed to hold

importance in infant development by nurturing or impeding

the development of self-regulation. Self-regulation, generally

defined as ‘the ability to regulate reactionsyand to function

more independently in a personal and social context, (pg 93)’

is said to have multi-dimensional influence on functioning,

including behavioral, emotional and cognitive actions.7 The

early development of this general capacity is profoundly

affected by supportive caregiver–infant interactions and it is

likely that these interactions have a similar impact on the

development of eating self-regulation. We present a model in

which a caregiver’s responsiveness that is congruent with

infant-feeding cues encourages the development of infant self-

regulation as it relates to energy intake, and eventually obesity.

Overweight and accelerated weight gain in infancy
and toddlerhood

The problem of pediatric overweight is evident before the

preschool years. Data collected in the National Health and
Received 21 June 2010; revised 6 December 2010; accepted 26 December

2010; published online 22 March 2011

Correspondence: Dr KI DiSantis, School of Medicine, Center for Clinical

Epidemiology and Biostatistics, University of Pennsylvania, 8th floor Blockley

Hall, 423 Guardian drive, Philadelphia PA 19104, USA.

E-mail: disantis@med.mail.upenn.edu

International Journal of Obesity (2011) 35, 480–

492

www.nature.com/ijo

http://dx.doi.org/10.1038/ijo.2011.3

mailto:disantis@med.mail.upenn.edu

http://www.nature.com/ijo

Nutrition Examination Survey 2007–2008 indicated that

approximately 10% of infants and toddlers were above the

95th percentile for weight-for-length; the prevalence was as

high as 14.9% in Hispanic males.8 These numbers are

of concern because heavy infants are at increased risk of

overweight in later stages of development.9,10 Analysis of the

CDC Pediatric Nutrition Surveillance System data revealed

that overweight infants (0–11 months) were 2.9–4.3 times

more likely to be overweight between the ages of 1 and 4

years than non-overweight infants.11 Accelerated weight

gain during the first 2 years of life, independent of birth

weight and parental weight status, has also been associated

with a greater risk of overweight during childhood12–17 and

young adulthood4,18–21 (see Stettler and Iotova22 for a

review). Though discussion of etiology has favored biological

explanations, caregiver–infant feeding interaction, like re-

sponsiveness, is implicit when considering the potential

contributing factors of infant weight gain.14,23

Caregiving and self-regulation among infants and
toddlers

Why might caregiver responsiveness be a formative dimen-

sion of feeding during the first 2 years of life?

Responsiveness

is a dimension of infant–caregiver interactions, which has

been said to shape an infant’s ability to acquire self-

regulation.7 Early relationships with caregivers engender an

infant’s development in numerous ways, but a supportive

environment to enhance the development of self-regulation

of energy intake holds unique importance for childhood

obesity risk. Supporting infant self-regulation of energy

intake may provide the necessary conditions to facilitate

development of regulatory capacity and autonomy through-

out infancy and into childhood. It is believed that infants

and young children are born with a nascent capacity for self-

regulation that becomes actualized through cause–effect

learning, which occurs when their behavior is consistently

met with a prompt, developmentally appropriate response.24

Responsive caregiving has been studied for decades in

domains outside of child feeding and growth, and has been

positively associated with a wide range of developmental

outcomes in infancy and early childhood including

emotional, language and cognitive capacity, as well as the

security of attachment to the mother (see Ziv et al.25 for a

review). Such synchronous interactions are thought to

provide fundamental support for opportunities to learn

mastery and self-regulation.26 Early infant emotions, for

example, stem from physical states, including temperature,

sleep states and hunger.7 Newborns exhibit emotional

reactivity to these physical states and express discomfort

via crying, but begin to show signs of self-regulated behavior

by 3 months of age.27 Examples of self-regulated behavior

include turning the body or head away from undesirable

stimuli and moving the hands toward the head and mouth.7

Caregivers support this developmental progression from

emotional reactivity to self-regulation by their consistent,

accurate and appropriate responses to infant cues, which

foster expectations in the developing infant about predict-

able patterns of interaction.7 However, accurate interpreta-

tion by caregivers is complicated by the fact that infant

crying can reflect discomfort due a variety of physical states

including sleep, temperature and hunger states.28 Thus, it

should be acknowledged that caregiver and child are

mutually influencing one another over time through the

consistency, meaning and appropriate interpretation of one

another’s behaviors.

Caregiver influences on the infant’s development of

self-regulation of feeding behavior parallels emotional devel-

opment. In their monthly feeding observations of 26 mother–

infant pairs over the first year of life, Ainsworth and Bell29

observed that mothers who exhibited more sensitive pacing

and prompt responses to the infant during feeding had infants

who cried less in early infancy and demonstrated greater

attachment to their mothers at the end of the first year,

compared with mothers who adhered to rigid feeding

schedules. This supports the hypothesis that caregiver respon-

sivity affects infant outcomes and development.30,31 However,

the relationship between caregiver and infant is bidirectional

and can also be affected by the clarity of infant cues.32,33 Some

infants demonstrate ambiguous signals, and have fewer

behaviors in general, including fewer elicited and spontaneous

vocalizations, fewer smiles, less gaze and joint attention and

poor signals to indicate their needs (including hunger cues). In

such cases, a caregiver’s responsiveness might be discordant

with infant needs (due to poor clarity of cues) or might be a

low level because few cues are exhibited.

To this notion, Wright and colleagues34,35 have argued

that appropriate responses to infant-feeding cues are critical

for self-regulation and self-control of food intake to develop

to its fullest potential. This argument is evidenced by

experimental studies, which have demonstrated that infants

as young as 6 weeks of age could adjust the volume of

formula intake in response to its energy content to maintain

daily energy intake.36–38 Observational research has also

provided evidence of such a capacity, including data from

3022 children (6 to 24 month old ) participating in the

Feeding Infants and Toddlers Study showing inverse relation-

ships between the number of daily feeds and the size of

feeds.39 In the context of developmental literature on

responsive parenting, self-regulation of energy intake in

infancy and toddlerhood is viewed as the extent to which

feeding environments and interactions allow the biological

potential of the child for self-regulation to be actualized.40

A potential role for responsive feeding

Although contribution of responsive feeding to self-regula-

tion and overweight in early development has been

Responsive feeding and infant overweight
KI DiSantis et al

481

International Journal of Obesity

suggested in scholarly writings for decades,35,41–44 systematic

inquiry appears limited. This review was undertaken to

characterize empirical support for the assertion that varia-

tion in the concordance of a caregiver’s responsiveness and

an infant’s hunger and satiety cues has a fundamentally

important role in growth by supporting energy self-regula-

tion in infancy and toddlerhood. Figure 1 presents the

conceptual framework that guided the review by articulating

potential pathways through which caregiver responsiveness

to infant-feeding cues influences child intake and growth.

Drawing from the developmental literature, feeding respon-

siveness is defined for the purposes of this review as prompt,

contingent and developmentally appropriate responses to

the child’s hunger and satiety cues.24,45 The bidirectional

nature of feeding is implicit in this definition, with the

caregiver dependent on the infant to provide clear, un-

ambiguous cues and the infant dependent on the caregiver’s

accurate interpretation of and appropriate response to those

cues for obtaining adequate and appropriate nutrition.

Given the aforementioned variance in the clarity of infant-

feeding cues, caregivers may be challenged to a lesser or

greater degree in their interpretation of cues. Likewise, less-

responsive caregivers may challenge the infant to provide

clearer cues (within a repertoire that may be relatively

limited in the first months of life). Thus, when we refer to

caregiver feeding responsiveness, we are referring to a

characteristic of the caregiver–child dyad’s level of concor-

dance in interactions during feeding. Responsiveness to

child-feeding cues has previously been included as part of an

internationally recognized framework of infant-care

practices oriented toward the prevention of malnutrition

and the support of child mental, social and physical

development.31,44,46 In that work, responsive feeding has

been broadly conceptualized to involve the caregiver’s

adaptation to the child’s psychomotor abilities for feeding

and provision of a structured feeding environment with a

goal of facilitating energy consumption to offset the effects

of malnutrition.44 In contrast, this review focuses solely on

the role of caregiver responsiveness to feeding cues in

supporting the capacity of infants to self-regulate energy

intake for optimal growth in a context of obesity risk.

Figure 1 was developed drawing from scholarly writing

dating back almost a half century.35,41–44 In this model,

discordant caregiver responsiveness to infant cues, specifi-

cally feeding without hunger and feeding beyond satiety, is

hypothesized to impair infant-satiety response. Such impair-

ments are suggested to promote energy intake beyond needs

for growth via increases in meal size and/or feeding

frequency. Overweight and rapid weight gain during infancy

and toddlerhood are the main growth-related outcomes of

interest. This model acknowledges feeding responsiveness as

being nested within a broader social-environmental context

that influences the way in which caregivers feed their

children,47 including cultural influences (e.g., ethnicity/

race48), policy and prevailing feeding guidance (e.g., World

Health Organization Recommendations on Breastfeeding49),

parental beliefs/goals/values,50 and parental knowledge of

development.51 These are all the factors brought in to the

feeding relationshipFand all can have considerable effects

on the relationship. This model acknowledges these ele-

ments, which are at the foundation of building a responsive

feeding relationship. The review was initiated to assess the

amount and quality of empirical evidence available to

support this

proposed model.

Materials and methods

Literature-search strategy

We performed a systematic literature review of responsive

feeding using the three major databases from three dis-

ciplines (medicine, psychology and nursing): MEDLINE via

PubMed (United States National Library of Medicine,

Bethesda, MD, USA), PsycINFO (American Psychological

Association, Washington, DC, USA) and CINAHL (Ebscohost,

Glendale, CA, USA). These databases were searched for

articles listed from the database’s inception to September

2009. Database limits were used to restrict the search to

research in humans and infants (from birth to 24 months).

As listed in Table 1, a list of 25 search terms were generated

by the research team to identify relevant articles addressing

Accelerated Weight Gain/
Overweight

Infant
Caregiver

Clarity of Hunger
and Satiety Cues

Discordant
Feeding

Responsiveness

Discordant
Feeding

Responsiveness

Increased Feeding
Frequency/Amount
Increased Feeding
Frequency/Amount

Accurate Interpretation

Developmentally
Appropriate Response

Awareness
Of Feeding Cues

Impaired Self-Regulation
•Diminished satiation/satiety

•Increased energy intake

Impaired Self-Regulation
•Diminished satiation/satiety

•Increased energy intake

Figure 1 Figure 1 presents a model for the pathway from discordant feeding

responsiveness to accelerated weight gain and/or overweight. This model

suggests that chronic mismatch between a caregiver’s responsiveness and an

infant’s feeding cues can result in increased feedings (amount and/or

frequency), which eventually lead to the acceleration of weight gain and

overweight via impaired infant self-regulation. A caregiver’s responsiveness

refers to both the amount and quality of responsive behaviors. The model

illustrates that caregiver and infant relationship is reciprocal, which is

impacted by the clarity of infant cues. The model also acknowledges that

the caregiver–infant dyad exists within a socio-environmental context, which

might impact the relationship.

Responsive feeding and infant overweight
KI DiSantis et al

482

International Journal of Obesity

the concepts outlined in the conceptual model (Figure 1),

including responsive feeding, self-regulation, feeding/

hunger cues, as well as terms related to obesity, such as rapid

weight gain. The phrases/terms in quotations were searched

for the exact phrase/term, whereas the other terms were not

put in quotations to allow for a variety of combination terms

to be searched. All search terms that included the word ‘Infant’

were repeated using the term ‘Child’ to ensure an extensive

search of the infant population.

Study selection and

grading

Article titles and their abstracts were briefly reviewed by the

first author (KI DiSantis) using the selection criteria. Those

that met and questionably met the inclusion/exclusion

criteria were then thoroughly reviewed for eligibility by all

the authors. Inclusion criteria included the following:

original research, published in English, published up to

September 2009, involving healthy full-term infants, aged

0–24 months of child age, including infant feeding/eating

and/or infant weight/growth outcomes, and oriented toward

child overweight/rapid weight gain and/or obesity. Owing to

concerns about socioeconomic and cultural consistency

across studies, and the goal of focusing on overnutrition

and obesity (as opposed to slow growth and malnutrition),

exclusion criteria included research conducted in developing

countries. In addition, given the focus on infant overweight

and obesity, research that focused on growth faltering

(organic or non-organic) or low birth weight was excluded.

Although including growth faltering and malnutrition

studies would increase the quantity of articles extracted,

they likely would not have added to the content of this

review as responsive feeding in these studies are investigated

in relation to a very different set of outcomes, including

promotion of energy intake and weight gain.

The quality assessment phase measured the level of

evidence provided by each included study and utilized the

Oxford University Centre for Evidence Based Medicine

(CEBM) levels of evidence system.52 This system was

developed to be an advancement of the Canadian Task Force

on the Periodic Health Examination grading system of 1979.

The ‘level’ of evidence is graded, primarily based on the rigor

of the study design (e.g., randomization in interventions),

sampling (e.g., response rate), longitudinal versus cross-

sectional, outcome assessment (e.g., negative assessment if

outcome measure is imprecise) and the follow-up rate, with

‘1a’ being the highest and ‘5’ being the lowest level. Levels of

evidence were independently assigned to the included

papers by two of the study authors. A consensus approach

was used to resolve discordant assessments, in which a third

reviewer independently graded the article and discussion by

all authors was used to assign a final rating.

Results

Systematic review results

The results of the systematic review are detailed in Table 1

and illustrated in Figure 2. The search of three databases with

25 aforementioned keywords provided 1877 hits. Owing to

the fact that these databases contain subscriptions to the

same journals or indexes, it was not possible to derive a

unique number of hits. After elimination of redundant

abstracts, 82 unique abstracts were deemed appropriate for

full-abstract review based on the first author’s brief review of

article titles and abstracts. These abstracts were then

thoroughly reviewed by all authors based on the a priori

inclusion/exclusion criteria described above to determine

whether they would be selected for final analysis. First, 14

articles were excluded because they were not original

research studies, performed research in a population other

than infants of 0–24 months and/or the research was

performed with regard to malnutrition/growth faltering

(Figure 2). The 68 remaining articles were assessed to

determine whether some aspect of infant/child obesity was

directly measured (eating behavior, intake weight and/or

growth) and whether caregiver-feeding practices/behaviors

were assessed (Figure 2). A total of 29 articles were excluded

because some aspect of infant overweight/obesity or infant

eating/intake outcomes was not directly measured. In most

of these excluded cases, feeding observations or other

feeding measures were used as a tool to investigate general

parental responsiveness or general infant–caregiver

Table 1 Systematic review search results by search term

Search terms Number

of hits

from three

databases

Abstracts

selected for

detailed

review

Abstracts

selected

as meeting

criteria

for CEBM

grading

Responsive feeding 6 5 0

Caregiver feeding styles 6 2 0

Rapid weight gain and eating 6 2 0

Infant feeding and responsiveness 85 13 0

Child feeding and responsiveness 43 0 0

Self-regulation and eating 19 3 0

Infant-feeding cue or infant-feeding cues 13 1 0

Parent feeding styles 12 1 0

Rapid weight gain and Feeding 24 3 1

Feeding interactions 94 13 1

Infant feeding practices 328 9 2

Feeding and satiety response 7 2 1

Infant and satiety response 8 4 0

‘Infant growth’ and overweight 107 2 0

‘Infant feeding’ and obesity 99 3 2

Child and hunger cues 10 0 0

Child and fullness cues 1 0 0

Infant and hunger cues 20 2 0

Infant and fullness cues 1 0 0

Satiety cues and infant 12 2 1

Satiety cues and child 3 0 0

Internal cues and infant 26 1 0

Internal cues and child 18 0 0

Self-regulation and infant nutrition 41 5 1

‘Care for development’ and feeding 888 9 0

Total 1877 82 9

Abbreviation: CEBM, Oxford University Centre for Evidence Based Medicine.

Responsive feeding and infant overweight
KI DiSantis et al

483

International Journal of Obesity

interaction, but the observations were never presented in the

context of infant eating/intake outcomes or were not

directed toward obesity outcomes child overweight/obesity.

Overall, 30 articles were excluded because of lack of

assessment of caregiver-feeding practices/behaviors, for

instance, in which feeding characteristics and infant growth

might have been assessed but no aspect of responsiveness

was measured. After screening all abstracts, a total of nine

articles met the inclusion/exclusion criteria and were

included in the systematic review (Figure 2).

The results of evidence-level grading for the nine articles,

based on CEBM criteria, are provided in Table 2. All articles

were graded as being a ‘2c’ level or lower level, meaning the

design was cross-sectional or a lower quality cohort study or

case–control study. Table 2 also provides additional details

related to the quality of the research studies, including

sampling characteristics, methods of measuring feeding

responsiveness and a brief outcome summary. Below we

briefly review these articles and their implications following

the framework of the conceptual model in Figure 1.

Narrative review

Socioenvironmental context of discordant responsiveness. Feed-

ing interactions take place within a wider social-environ-

mental context, consisting of a wide range of factors like

biobehavioral issues, culture, psychosocial status, physical

environments and history at individual, family and com-

munity level. Mogan53 was the only article in the review that

considered context, by evaluating associations of both

parental and infant weight status with maternal sensitivity

to infant cues. Parental weight status is an individual-

level

variable, but in this study they accounted for the differences

between dual and caregiver households with varying combi-

nations of parents classified as normal or overweight.

Parental weight status was categorized into three groups:

(1) two normal weight parents, (2) one overweight and one

normal and (3) two overweight parents. Mothers and infants

were observed during six feeding sessions from age 0 to 6

months to assess feeding interactions. The observations were

coded using the Nursing

Child Feeding Assessment Scale,

which contained the following subscales: mother’s sensitiv-

ity to cues, response to distress, social –and emotional

growth fostering, cognitive fostering and the infant’s clarity

of cues and responsiveness to their mother. This measure,

particularly the mother’s sensitivity to cues and infant

responsiveness subscales, allowed for the assessment of

discordance in responsiveness in a bidirectional manner as

presented in Figure 1. Although the methodology was

strong, the authors did not find that these responsive

feeding behaviors of the mother and/or infant differed

among the parental weight groups. However, infant weight

status differed significantly at 6 months of age according to

parent weight group, with infants who had one or two

overweight parents being more likely to be at or above the

90th percentile for weight. Mogan53 did not report on

relationships between maternal feeding responsiveness and

infant weight status at 6 months, so it is unclear whether any

relationship existed in this sample. Although this study used

observational data, which assessed the bidirectional feeding

relationship, it neither found relationship between parental

weight status and responsive maternal–infant feeding inter-

actions nor did it report on the association of responsive

feeding with infant weight at 6 months. Other studies of

older children have connected maternal weight status with

unresponsive feeding practices (i.e., restriction in feeding),54

but are outside the developmental scope of this review.

Discordant responsiveness and feeding frequency and amount. As

Figure 1 illustrates, discordant responsiveness in feeding

might lead to increased feeding frequency or amount.

Numerous circumstances of discordance could combine to

result in increased feeding frequency (including feeding an

infant in the absence of hunger cues, misperception of

hunger cues) and increased amounts of food (including

ignoring fullness cues, or misperception of fullness cues). If

this were to continue over a period of time, the risk of

increased energy would increase. Kavanagh et al.55 per-

formed a double-blinded, randomized intervention, which

focused on using education on feeding responsiveness and

prevention of overfeeding to reduce the risk of overfeeding

(infants were 3–10 weeks at enrollment). The control group

82 studies identified for full abstract review

4 excluded due to not being
original research

8 excluded due to sample being
malnourished, premature, or
having other health problem

involved in eating and/or weight

68 studies performed in samples
with healthy infants 0-24

months

9 original research studies performed in samples
with healthy infants 0-24 months with

obesity

outcomes and measuring and/or feeding and eating
included in evidence-based systematic review

78 studies original research

76 studies performed in
sample aged 0-24 months

39 studies performed in samples
with healthy infants 0-24 months

with obesity outcomes

29 excluded due to outcome not
being a direct measurement of

obesity

30 excluded child eating or
maternal feeding was not either

predictor or outcome

2 excluded due to sample age

Figure 2 Flow diagram of article extraction.

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KI DiSantis et al

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International Journal of Obesity

Table 2 Systematic review results

Article Design, setting and variables Sample

characteristics

Measure of responsiveness

(type, description)

Summary of results CEBM

level

assigned

Social-environmental context of discordant responsiveness

Mogan53 Design: prospective cohort

Setting (country): US

Independent variable(s)/intervention:

Parents’ weight status (1 parent

overweight, 2 parents overweight,

2 parents normal weight)

Outcome(s): parent–child

interaction during six feedings

from 0 to 6 months and infant

weight status.

n¼78 for feeding

behavior

analysis

n¼62 for infant

weight status

analysis

Age: 55–70 h

Age(s) at

follow-up:

0–6 months

Race/ethnicity:

88.5% White,

5.1% Asian, 2.6%

East Indian, 1.3%

Black and 2.6%

other.

Type: observational measure

Description of measure: Nursing

Child Feeding Assessment Scale,

subscales: maternal sensitivity to

cues, clarity of child cues, child’s

responsiveness to parent during

feeds.

Feeding behaviors did not differ

among the parental weight groups

but a higher proportion of infants

with two overweight parents

had a growth percentile X90th

percentile

6 months.

Discordant responsiveness and increased feeding frequency/amount

Kavanagh

et al.55

Design: double-blind, RCT

Setting (country): US

Independent variable(s)/intervention:

educational intervention with

general feeding guidelines and

information on awareness of

infant-satiety cues (single, 45-min

session); Control participants

received general feeding

guidelines only.

Outcome(s): formula intake

(ml h�1; non-weighed, 2-day

record) and weight gain.

n¼61 at BSL

n¼38 at follow-up

Age: 3–10 weeks

Age(s) at follow-

up: 4–5 months

Race/ethnicity: not

reported.

Type: Educational intervention

Description of measure:

intervention group received

feeding responsiveness

education, in addition to

general infant-feeding

guidelines.

The intervention group did not

differ significantly in formula intake

or weight gain in the hypothesized

direction, as the control group

reported lower formula intake

at 4–5 months and the intervention

group had greater weight gain

(grams per week).

Discordant responsiveness and impaired self-regulation

Rybski et al.56 Design: cross-sectional

Setting (country): US

Independent variable(s)/

intervention: maternal behaviors

during bottle feedings during six

feedings over a 24-h periods

Outcome(s): Infant-eating

behaviors (total feeding time,

sucking behaviors) and Infant

energy intake (24-h weighed

record).

n¼10

Age: 72 h

Race/ethnicity:

100% White.

Type: Observational measure

Description of measure:

observed maternal behaviors

during feedings (verbal

interaction, eye contact,

tender and caretaking

touching).

No association between the

measured maternal feeding

behaviors and either infant

eating behaviors or 24-hour

energy intake, but it is important

to consider that mothers were

not allowed to hold their infants

during any feeds, which would

clearly limit the amount of

behaviors a mother can perform.

Discordant responsiveness and infant weight gain/overweight.

Baughcuma

et al.70 Design: cross-sectional

Setting (country): US

Independent variable(s)/intervention:

child overweight (o90th percentile)

and mother’s obese status

(BMI X30)

Outcome(s): infant-feeding

styles.

n¼453

Age: 11–24

months

Race/ethnicity:

77% non-Hispanic

White, 16.6% non-

Hispanic Black,

1.4% Hispanic

White and 5%

others

Type: Self-report survey

Description of measure: Infant

Feeding Styles Questionnaire

(IFQ), subscales: Awareness of

infant’s hunger and satiety

cues, Feeding infant on

schedule, using food to calm

infant’s fussiness, social

interaction with infant

during feeding

The IFQ subscales failed to associate

responsive feeding behaviors to

concurrent weight status of either

infant (11–23 months) or mother.

Dubois et al.69 Design: case–control

Setting (country): Canada

Independent variable(s)/intervention:

Infant weight status (Obese cases

(o90th percentile), normal controls

(25th–75th percentile))

Outcome(s): energy intake (3-day

non-weighed, record) and

maternal-feeding practices

n¼89 (47 cases,

42 controls)

Age: 4–9 months

Race/ethnicity: not

reported.

Type: qualitative self-report

Description of measure:

Open-ended questions on

mother’s past feeding practices

(e.g., breastfeeding) and

mother’s concepts and

attitudes toward infant

feeding.

Maternal responsiveness was an

identified theme. Obese and control

infants did not differ in the following

maternal responsiveness to feeding,

energy intake, or in her timing of

breastfeeding cessation or

supplementation introduction.

Responsive feeding and infant overweight
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International Journal of Obesity

(n¼ 21) received a 45-min educational session on general

guidelines for infant feeding, including appropriate age of

introduction of complementary foods, safe preparation of

complementary foods, responsive feeding practices, when

feeding complementary foods, and information on low-cost

ways of providing nutritionally balanced meals. The inter-

vention group (n¼19) was given similar information but

additionally provided with educational information on

being aware of infant-satiety cues when breastfeeding or

bottle feeding (e.g., understanding early versus late cues) and

were encouraged to only prepare 6 ounces of formula per

feeding. The outcome measures were both infant weight and

length and formula intake (measured at baseline, 2 weeks

after the class and at about 4 months. Kavanagh et al.55

found no differences between the intervention and control

groups with regard to formula intake at any of the time

points and bottle-emptying behavior, and conversely the

intervention group infants were heavier and taller at 4

months. Thus, this study did not provide support for the

conceptual model. Kavanagh et al.55 acknowledged short-

comings in this small study including that at baseline

the intervention group infant’s were taller and heavier than

the control group, the bottle records were not weighed

and a considerable loss to follow-up rate with only 38%

Table 2 (continued)

Article Design, setting and variables Sample

characteristics

Measure of responsiveness

(type, description)

Summary of results CEBM

level

assigned

Farrow and

Blissett62

Design: prospective cohort.

Setting (country): UK

Independent variable(s)/intervention:

Maternal control in feeding

at 6 months.

Outcome(s): Infant growth

(standardized to reference

adjusting for age and gender)

from birth to 6 months and from

6 to 12 months.

n¼69

Age: 6 months

Age(s) at

follow-up:

12 months

Race/ethnicity: not

reported.

Type: observational

Description of measure: Feeding

Interaction Scale, a coding

system for feeding observations

measuring maternal control

and infant autonomy.

Maternal control moderated infant

weight gain, with infants’ low

control mothers regulating their

growth from birth–12 months

and infants’ high control mothers

having poor growth regulation.

Breast-fed infants had mothers

that were less controlling

than non-breastfed infants.

Li et al.64 Design: -prospective cohort

Setting (country): US

Independent variable(s)/intervention:

BF intensity (% all milk feedings

that were breastmilk) and bottle–

emptying behaviors (maternal

self-report), at multiple time

points from 1 to 6 months.

Outcome(s): excess infant weight

gain from 7 to 12 month old.

n¼1896

Age: B1 month

Age(s) at follow-

up: 2–12 mon

Race/ethnicity:

83.6% non-

Hispanic White,

6.9% non-Hispanic

Black and 9.5%

Hispanic.

Type: Self-report survey

Description of measure: survey

of infant’s bottle use behavior

(four 5-point Likert scale

questions), focused on bottle

emptying and mother’s

encouragement to finish

a bottle.

High breastfeeding intensity resulted

in significantly reduced excess weight

gain. Infants who often emptied

bottles in the first 6 months of life

were 69% more likely to have excess

weight gain in the second half of

infancy, compared with those who

rarely emptied bottles, but mother’s

self-reported encouragement to

empty bottles was not related to

excess weight gain.

Saxon et al.60 Design: retrospective cohort

Setting (country): US

Independent variable(s)/intervention:

Infant weight, length, head

circumference at birth, 2, 4- and

6 months.

Outcome(s): mother’s reported

feeding practice from birth to

9 months.

n¼48

Age: 12 months.

Race/Ethnicity:

81% White, 11%

Hispanic, 3% black

and 3% Asian.

Type: Self-report survey

Description of measure: feeding

practices survey (14-items)

focused on demand and

scheduling feeding (e.g., who

(mother or baby) determined

when the baby ate; does

mother recognize fussiness

as a hunger cue).

Feeding style (on-demand versus

scheduled) was not associated with

any growth variables across the first

year of life. However, predicting

growth changes based on current

feeding styles might not capture

the prospective effect of feeding

on growth, as current feeding

behaviors might have changed in

response to infant growth changes.

Worobey et al.65 Design: prospective cohort.

Setting (country): US

Independent variable(s)/intervention:

maternal sensitivity to infant-feeding

cues and infant-feeding record

(24-h recall) at 3 and 6 months.

Outcome(s): Infant weight gain

from birth–3 months, 3–6 months

and 6–12 months.

n¼96

Age: newborn

(enrolled at first

WIC visit)

Age(s) at

follow-up: 3, 6

and 12 months.

Race/ethnicity:

76% Hispanic and

24% Black.

Type: observational

Description of measure:

maternal sensitivity to cues

subscale of the Nursing Child

Feeding Assessment Scale.

Infants gained more from 6 to 12

months if their mothers were less

sensitive to satiety cues. Also, infants

whose mother’s reported a greater

number of feeds per day had greater

growth from 6 to 12 months.

Growth between other time points

were not significantly related to the

feeding variables.

Abbreviations: BMI, body mass index; BSL, baseline; BF, breastfeeding; CEBM, Oxford University Centre for Evidence Based Medicine; RCT, randomized control trial;

UK, United Kingdom; US, United States; WIC, United States Special Nutritional Supplement Program for Women, Infants and Children. aNote: Two studies were

presented within this article, but only the study performed within an infant sample was presented in this review.

Responsive feeding and infant overweight
KI DiSantis et al

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International Journal of Obesity

of the original sample completing both the class and the

assessments.

Rybski et al.56 similarly studied the associations between

maternal feeding behaviors and infant intake, in a small

sample of 3-day-old female, white infants. Although the

study observed maternal behaviors related to responsiveness

during bottle feedings (i.e., verbal interaction, eye contact,

tender and caretaking touching), the purpose of the study

was to observe changes in sucking behaviors and intake of

formula across a 24-h period to understand the potential

effects of circadian periodicity. The feeding variables (e.g.,

total feeding time, nutritive sucking time nutritive sucking

count) were measured during six observations set at the same

time for all participants across a 24-h period in a stimuli-free

room, with controlled temperature and lighting. This study

did not find an association between maternal feeding

behaviors and infant energy intake. A potential source of

bias for evaluating feeding responsiveness was that mothers

were not allowed to hold their infants during any feeds,

which could have limited the amount and type of (e.g.,

touching) behaviors a mother was engaged in during a

feeding. In view of these shortcomings of these studies,

additional research is needed to evaluate the effect of

caregiver awareness of infant-feeding cues on infant energy

intake and subsequent weight gain.

Discordant responsiveness and impaired self-regulation. As

shown in Figure 1, we suggest that caregiver feeding

responses that are discordant with infant hunger and

fullness cues could led to impaired satiety response in the

infant. Experimental and observational studies have shown

that infants and toddlers possess an ability to self-regulate

energy intake at and across eating occasions by adjusting

food intake in response to changes in feeding frequency and

the energy content of foods consumed.57–59 Responsive

caregiving is believed to promote cause (i.e., infant cue)

and effect (i.e., caregiver response) learning that is central to

the development of self-regulation.24 Some have suggested

that chronically unresponsive feeding may negatively influ-

ence what children learn about when eating should begin

and end.40,41 This systematic review, however, did not

identify any research that has evaluated the assertion that

feeding interactions affect infant satiation. As such, there is

currently no evidence to suggest that responsiveness influ-

ences child self-regulation of energy intake in infancy or

toddlerhood. The notion that feeding children in the

absence of hunger and continuing to feed beyond fullness

is detrimental to the development of self-regulation has

appeared in scholarly writing for well over half a century.

The findings of this review suggest the need for research

explicitly measuring dimensions of appetite regulation,

including hunger, satiety and satiation. Owing to a lack of

studies and negative finding, evidence that feeding respon-

siveness influences infant self-regulation of energy intake

remains weak.

Discordant responsiveness and accelerated weight gain and
overweight

Compared with other areas of the model, a relatively greater

number of studies were identified involving the association

of responsiveness to infant cues with infant weight status

and weight gain. Saxon et al.60 studied maternal feeding

behaviors and subsequent weight gain. The feeding beha-

viors focused on in Saxon et al.,60 measured whether a

mother reported using demand or schedule feeding in the

first 6 months of life, rather than more directly assessing

responsiveness as we have described. However, the authors

describe demand feeding in the same manner as we have

describe responsive feeding, in which the caregiver would

initiate feeding in response to infant-hunger cues, rather

than based on the external factor of time. Mothers retro-

spectively self-reported their feeding practices from birth to

6 months, and were then classified as demand or schedule

feeders based on the answers to these two questions:

(1) I would classify my feeding philosophy as: (answers:

‘Feeding on demand’ or ‘Feeding on a schedule’) and (2) Who

would you say usually determined your baby’s eating routine?

(answers: ‘Me (myself/caregiver)’ or ‘Baby’). They reported

that feeding style did not significantly predict infant weight

gain at 2, 4 and 6 months (controlling for birth weight).

Although Saxon et al.60 findings do not support a relationship

between maternal feeding style and infant’s future weight

status as proposed in the model, a few shortcomings must be

noted. Foremost, demand versus scheduled feeding does not

explicitly capture ‘responsive feeding’ as we have defined it.

Also breastfeeding was not controlled for during analyses,

even though it has been linked to growth particularly in the

first 2 years of life,61 and the two groups had differential levels

of breastfeeding.60 Lastly, evaluating growth (i.e., change with

time) may have been more informative than assessing weight

at each time point controlling for birth weight.

Farrow and Blissett62 examined a well-researched aspect of

responsive feeding, maternal control and its moderating

effects on infant weight gain in the first year of life. Relative

to the other studies reviewed, the maternal behavior of

interest was well aligned with the definition of ‘responsive

feeding’ used here. Maternal control was measured through

the systematic coding of feeding observations (using the

Feeding Interaction Scale,63 in which the observer rates the

mother on a 1–9 scale, with 1 equaling a very controlling

caregiver (e.g., mother is continuously forcing the infant to

eat) and 9 equaling not controlling (e.g., mother is allowing

the infant autonomy to control his or her own feeding,

although supervising the infant). Infant weight was mea-

sured at 6 and 12 months (birth weight was taken from

hospital records). They found that infant weight gain from

birth to 6 months, and from 6 to 12 months were negatively

correlated, indicating that infants appear to self-regulate

their weight in the first year of lifeFhowever, this was only

found in infants with low maternal control in feeding.

Infants with high-maternal control in feeding had the

opposite patternFweight gain from birth to 6 months and

Responsive feeding and infant overweight
KI DiSantis et al

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International Journal of Obesity

from 6 to 12 months was positively correlated, so that a high

weight gainer from birth to 6 months would continue on the

path of high weight gain. This suggests that, although

infants have the capability of self-regulation of energy intake

and weight gain, there is an interaction with the environ-

ment (caregiver feeding control) that can modify the

expression of this potential. Farrow and Blissett’s62 work

offers insight into the role of one aspect of responsive

feeding (maternal control) and infant growth. The prospec-

tive nature of the study along with rigorous measures helps

to add support to the model proposed here.

In a more recent investigation identified, Li et al.64

reported on a population-based survey of US mothers, which

investigated whether breastfeeding duration and frequency,

and exclusiveness and bottle-emptying practices predicted

excess infant weight gain in the interval between 6 and

12 months. These feeding practices were self-reported at

multiple time points from birth to 6 months. Findings

revealed that infants who often emptied bottles in the first 6

months of life were 69% more likely to have excess weight

gain in the second-half of infancy (6–12 months), when

compared with those who rarely emptied bottles.64 Also,

high breastfeeding intensity (combination of duration and

frequency) resulted in significantly reduced excess weight

gain. This study explores the ‘what’ of infant feeding

(breastmilk versus formula), which is often focused on with

relation to obesity, but also explores the ‘how,’ through the

effects of bottle emptying. These findings highlight

behavioral aspects of infant feeding, which affected infant

weight gain in this large sample (n¼1896). An issue in

interpreting these findings is the extent to which bottle-

emptying behaviors reflected infants’ appetites versus

caregivers’ responsiveness to infant-feeding cues. Additional

research is needed to address this issue.

Worobey et al.65 assessed the association of infant growth

with maternal-feeding attitudes related to responsiveness for

their association with infant growth in a sample of low

income, minority women and their newborn infants.

Maternal ‘pushiness’ during feeding (using the Maternal

Feeding Attitudes Questionnaire66) and maternal sensitivity

to infant cues (using the Nursing Child Assessment Feeding

Scale67,68) were assessed in relation to infant growth from

birth to 12 months. After controlling for numerous factors

(such as birth weight, gender, race/ethnicity, maternal age,

maternal body mass index before pregnancy), infant weight

gain between 6 and 12 months was predicted by mothers’

sensitivity to satiety cues such that low-maternal sensitivity

to infant cues resulted in increased weight gain. It should be

noted that infant growth measures lacked standardization, as

change in actual weight was investigated (i.e., weight gained

from 6 to 12 months of age), no change in growth based on a

standardized growth reference (i.e., weight-for-age Z-score

change). As a result, the changes in growth only speak to

change to one’s own baseline not in reference to whether the

individual’s growth would trail, equal or exceed other

individual’s of similar gender and age.

Two studies were identified that assessed infant obesity/

overweight in relationship with responsive feeding. Dubois

et al.69 sampled two groups of infants; 42 normal weight 4–9

months old (25–75th percentiles and 47 overweight 4–9

months old (o90th percentile). They investigated whether

these two groups differed in energy intake, infant feeding

history and maternal reliance on external cues. For ‘maternal

reliance on external cues’, mothers were asked open-ended

questions and their answers were coded with respect to the

following variables: mother usually uses external cues to

initiate or terminate feedings, sometimes tries to feed more

or less than the infant wants and sometimes offers food to

stop infant’s crying. External cues were described as time or

prepared portion of formula/food and infant signals were

described as sucking fingers (hunger) or turning head away

(fullness). Dubois et al.69 found no differences in maternal

reliance on external cues among the groups of overweight

4- to 9-month-old infants (o90th percentile) and normal

infants (25–75th percentiles). However, the method of

measuring maternal feeding responsiveness was not standar-

dized as open-ended questions were used, which had not

been previously validated. Baughcum et al.70 investigated the

affect of maternal-feeding behaviors on weight in an infant

sample (aged 11–23 months). A separate sample of pre-

schoolers was assessed as part of this study;70 however, those

results are not discussed given the focus of this review on

infants and toddlers. Within the infant sample, a number of

aspects of maternal feeding in which responsiveness is

implicit were assessed for the association with infant weight

status, including concern about the infant’s weight (either

over- or underweight), concern about the infant being

hungry, using food to calm the infant and establishing a

feeding schedule. However, no associations were identified

between a particular feeding style and overweight in infants.

Income was found to influence feeding behaviors, for

example low-income mothers of infants reported more

concern about infant hunger and feeding infant on a

schedule. Thus, the findings of Baughcum et al.70 did not

add support for the model. But a criticism is that the purpose

of the study was in part to validate the questionnaires

usedFthese new questionnaires might have failed to

elucidate responsive feeding behaviors. For example, mater-

nal control in feeding, commonly measured through the

validated Child Feeding Questionnaire,71 has previously

been connected with child overweight,72,73 yet in this study,

control was not associated with child overweight. Also

measuring concurrent weight and feeding behaviors might

not reflect any of the effects from feeding behaviors in

infancy on later childhood overweight. Most of the evidence

was gathered to support the connection between responsive

feeding and weight gain/overweight as presented in the

model, and of the six studies identified, three added support.

Summary of the systematic review findings

The evidence gathered was rated at 2b or lower level of the

CEBM system, meaning there was a dearth of high-quality

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KI DiSantis et al

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International Journal of Obesity

prospective work. Of the nine studies described here, only

three studies (Farrow and Blissett62; Li et al.64; Worobey

et al.65) revealed associations with dimensions of feeding

responsiveness as described for the model. Although these

studies provide preliminary support for an influence of

responsive feeding on infant/toddler weight, there was a

notable lack of evidence to substantiate the assertion that

such a relationship is produced by excessive energy intake.

Further, the methods for measuring responsive feeding as

reviewed in this narrative and as presented in Table 2,

generally reveal a lack of consistency in the manner in which

feeding responsiveness has been operationally defined. This

concern, along with the failure to consider the bidirectional

nature of maternal responsiveness and infant behaviors,

points to the need for further exploration.

Discussion

This systematic review offered the opportunity to describe

the rationale for investigating responsive feeding and over-

weight during infancy and toddlerhood and to assess the

state of the science on this topic. The conceptual model

provided a framework for identifying and thematically

organizing scientific literature on this topic. The systematic

approach adopted here revealed a dearth of rigorous inquiry

on this topic. The three studies that provided the strongest

support for the model (Farrow and Blissett62; Li et al.64;

Worobey et al.65) evaluated maternal responses to satiety

cues and/or bottle-emptying behaviors and their association

with infant growth. Only Li et al.,64 however, assessed

feeding interactions in a longitudinal manner. In general,

all the articles retrieved, supportive or not, lacked prospec-

tive assessments of infant–caregiver interactions as they

relate to self-regulation, growth and obesity, which was

evidenced by the relatively low CEBM levels assigned to the

studies gathered. This is a crucial gap in the current literature

in light of recognition that feeding interactions are nested in

developmental phases. So that capturing caregiver–infant

interactions at one time point only provides insight into that

point in development. That there was a shortage of support

for the proposed model from the primarily cross-sectional

studies in this systematic review should not discourage

further inquiry.

Beyond the dearth of longitudinal work in this area, the

assessment of the dynamic nature of caregiver–infant

feeding interactions is notably lacking. Responsiveness can

be conceived of as a reciprocal dimension of feeding in

which children are responsible for providing clear feeding

cues and the caregiver for responding in a prompt and

developmentally appropriate manner. However, rather than

focusing on how bidirectional aspects of feeding relate with

obesity outcomes (increased energy intake, rapid weight gain

overweight), studies have focused on how infant-eating

behaviors or caregiver (primarily maternal)-feeding

behaviors independently affect these outcomes. This is

potentially because of the lack of assessment tools, which

measure interactions in a dynamic manner, rather than

assessing the infant or the caregiver alone. To move knowl-

edge ahead in the area of feeding behaviors and obesity

prevention, it is necessary to begin to assess the dyad. Such

assessments would aid in evaluating the usefulness of the

proposed model.

In addition to the alternating focus on either infant or

caregiver behaviors, there was a noteworthy lack of consis-

tency in measurement of ‘responsive feeding.’ The variation

in measurement is illustrated by the variety of constructs

reported on by the articles in this review (Table 2). Variables

used to represent responsive feeding included demand/

schedule feeding,60 bottle emptying,64 observational mea-

sures (e.g., NCAST)56 and self-report measures of caregiver

behaviors.62,70 An additional complicating factor is that

previous research in responsive feeding has been largely

oriented toward undernutrition and has conceptualized

feeding responsiveness more broadly than is considered here

for obesity prevention. Measuring responsive feeding in the

framework of obesity prevention may require a different

operational definition of responsive feeding than those used

in the context of undernutrition. In the model explored

here, discordant responsiveness leads to increases in infant

intake, which could lead to chronic energy imbalance and,

eventually, overweight. The relatively new interest in

viewing responsive feeding in the context of child obesity

risk may explain the lack of concerted study on this topic.

Why has feeding responsiveness been largely ignored in

efforts to understand the development of overweight?

Exploration of feeding dynamics and their role in intake

and growth requires a multidisciplinary perspective invol-

ving parenting, pediatric nutrition and child development.

Psychologists have long studied feeding, but viewed it

primarily as a vehicle for studying parent–child relationships

and developmental outcomes other than growth rather than

as phenomena of interest unto itself. Nutritionists have

historically viewed children’s eating behavior in terms of

food and nutrient intake rather than feeding and eating

behavior. As a result most knowledge related to feeding

pertains to what children are fed rather than how children

are fed. Recognition of environmental contributions to

pediatric overweight and challenges to its treatment have

only recently directed scholarly interest toward understand-

ing familial influences on the development of eating

behavior.

Acknowledging that the caregiver–infant dyad and family

is situated within a broader socioenvironment context

encompassing among others, cultural beliefs/practices about

parenting and feeding, policy, education, healthcare and

childcare, it is clear that a great deal of work remains to be

carried out to begin to understand the complexities of

interactions among these factors and the intrapersonal and

interpersonal factors we think shape dyadic feeding inter-

actions. It is overwhelming and beyond the scope of any

Responsive feeding and infant overweight
KI DiSantis et al

489

International Journal of Obesity

single study to undertake such a task, but such a broad

conceptual model as proposed here is useful to the field at

large, pointing to particular relationships that are un- or

underexplored and highlighting areas in which interdisci-

plinary collaborations could be fruitful. As first steps in

advancing knowledge in this area, we offer some suggestions.

The development of well-operationalized and rigorously

developed measurement tools is clearly a priority for moving

scientific inquiry forward in this area. Rigorous observational

approaches should be considered in initial research efforts to

characterize feeding responsiveness and to identify dimen-

sions for which self-report may be possible.74 Qualitative

methods may also prove fruitful to identify potential

facilitators and barriers to responsiveness, such as caregiver

feeding knowledge, attitudes and beliefs. Longitudinal

studies will be required to draw inferences about the capacity

of responsiveness to modify child nutritional and growth

trajectories. Beyond closing in on the caregiver–child inter-

actions, a multidisciplinary approach must be taken to

address the complexity of both caregiver–infant interactions

and obesity and how and whether responsive feeding relates

to the entire growth spectrum (undernutrition to obesity).

Points of exploration, include experiences of the infant and

caregiver during feeding from mood and stress,75,76 altera-

tions in neurohormones77 and racial/ethnic differences and

cultural beliefs, which might alter caregivers’ attitude to

optimal responsiveness, can be investigated.78,79 Thus,

efforts to understand the development of infant/child eating

behavior and its importance for growth should take feeding,

its goals and its context into consideration. The dependence

of infants and toddlers on their caregivers to obtain nutrition

and develop eating skills suggests a potentially critical role

for responsive feeding in nutrition and growth from a very

early point in development. A recent study of overweight

children illustrates the need for such early interventions, as

it found that nearly 60% of overweight children became

overweight before the age of 2 years.3 As a potentially

modifiable behavior, responsiveness may represent an

efficacious target for early obesity prevention efforts in the

future.

Conclusion

In conclusion, the notion that a chronic mismatch between

feeding and child cues contributes to the development of

overweight is not new.29,41 On the basis of the findings of

this systematic review, however, the role of feeding respon-

siveness in accelerated growth and overweight remains, to

date, is more speculative than substantive. There is pre-

liminary support for the proposed role of responsiveness in

growth during early development, though the strength of

evidence is relatively weak and the studies are few. These

findings underscore that we are in the early stage of

empirical research on this topic. As such, we conclude that

additional rigorous investigation of feeding responsiveness is

needed, particularly longitudinal studies, within the frame-

work of early obesity prevention efforts among diverse

populations.

Conflict of interest

The authors declare no conflict of interest.

Acknowledgements

This work was supported by the NIH K01 DK 61319-01

(Fisher), USDA 2005-55215-6 16726 (Johnson), NIH DK

56350 (Hodges), RWJF 66523 (Hodges) and Nestle Infant

Nutrition (Fisher).

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Responsive feeding and infant overweight
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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

c.ijo20113a

The role of responsive feeding in overweight during infancy and toddlerhood: a systematic review

Introduction

Overweight and accelerated weight gain in infancy and toddlerhood

Caregiving and self-regulation among infants and toddlers

A potential role for responsive feeding

Materials and methods

Literature-search strategy

Figure 1 Figure 1 presents a model for the pathway from discordant feeding responsiveness to accelerated weight gain and/or overweight.

Study selection and grading

Results

Systematic review results

Table 1 Systematic review search results by search term

Narrative review

Socioenvironmental context of discordant responsiveness

Discordant responsiveness and feeding frequency and amount

Figure 2 Flow diagram of article extraction.

Table 2 Systematic review results

Outline placeholder

Discordant responsiveness and impaired self-regulation

Discordant responsiveness and accelerated weight gain and overweight

Summary of the systematic review findings

Discussion

Conclusion

Conflict of interest

Acknowledgements

References

_______________________________________________________________

_______________________________________________________________
Report Information from ProQuest
February 10 2015 14:37
_______________________________________________________________

10 February 2015 ProQuest

Table of contents

Child-care usage and mother-infant “quality time”

…………………………………………………………………………… 1

10 February 2015 ii ProQuest

Document 1 of 1

Child-care usage and mother-infant “quality time”
Author: Booth, Cathryn L; Clarke-Stewart, K Alison; Deborah Lowe Vandell; McCartney, Kathleen; Margaret
Tresch Owen
ProQuest document link
Abstract: Mothers’ time-use paterns were compared in families in which infants spent more than 30 hours per
week in child care (In-Care group; n = 143) versus 0 hours per week (At-Home group; n = 183) from birth to 6
months of age. In-Care group mothers spend about 12 fewere hours per week interacting with their infants, for
about 32% less time; fathers of these infants were more involved in caregiving.
Full text: Headnote
Mothers’ time-use patterns were compared in families in which infants spent more than 30 hours per week in
child care (In-Care group; n = 143) versus 0 hours per week (At-Home group; n = 183) from birth to 6 months of
age. In-Care group mothers spent about 12 fewer hours per week interacting with their infants, for about 32%
less time; fathers of these infants were more involved in caregiving. The groups did not differ in the quality of
mother-infant interaction. In the In-Care group, quantity of in
Headnote
teraction was related to greater separation anxiety and concerns about effects of maternal employment. Time-
use data were not related to child outcomes at 15 months of age. Results suggest that the effect of extensive
time spent apart on the quantity and quality of mother-infant interaction may be smaller than anticipated.
Headnote
Key Words: child care, mother-infant interaction, time use.
Dramatic increases in the labor force participation of women with young children in the United States have led
to a concomitant increase in the use of early and extensive nonmaternal child care, usually beginning in the
early months of life (Hofferth, Brayfield, Deich, &Holcomb, 1991). The increasing use of extensive child care in
early infancy has generated scientific debate about the effects of child care on children’s development and the
mother-child relationship (see Lamb, 1998). One of the chief concerns is that early entry into child care may
have a negative impact on the ability of the mother and infant to develop a synchronous relationship. That is,
long hours spent apart may provide insufficient time for the mother to learn about her infant’s cues and
biological rhythms (Brazelton, 1986), and her appropriate and sensitive responses to these cues are vital for
fostering the infant’s optimal development (see Kelly &Barnard, 2000).
A particular area of concern is the infant’s attachment security to the mother. According to attachment theory,
the degree of mother-infant sensitivity and responsivity forms the basis for the development of the infant’s
secure (or insecure) attachment to her (see De Wolff &van Ijzendoorn, 1997). The security of this attachment, in
turn, is important because it predicts children’s subsequent peer relations, affect regulation, selfesteem, ego
resiliency, and behavior problems (see Thompson, 1998). Thus, to the extent that maternal sensitivity and
responsivity decrease when the mother and infant spend long hours apart, then we would expect an increase in
the risk of insecure attachment and other less optimal outcomes.
Infants form important and independent attachments to their fathers and other caregivers as well. However, a
comparison of the relative influence of infant-mother and infant-father attachment on child outcomes has
indicated that the infant-mother relationship is a stronger predictor (Thompson, 1998). These results, coupled
with concerns about the effects on children of large increases in maternal employment hours, have led to a
focus on the early mother-child, rather than father-child, relationship within the child-care and employment
literature.
Within the child-care literature, several studies focusing on early infancy have supported the hypothesis of a

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negative association between the amount of child care and the quality of motherinfant interaction, but the
majority of researchers have not (see National Institute of Child Health and Human Development Early Child
Care Research Network [NICHD ECCRN], 1999, for a review). Analyses from the NICHD Study of Early Child
Care are especially relevant in this regard, because a subset of these data were used in the present report.
Longitudinal analyses of the main data set indicated that greater hours per week in child care were related to
somewhat less maternal sensitivity and child engagement in mother-child interaction in the first 3 years of life
(NICHD ECCRN, 1999). However, this relatively small decrease in the quality of mother-child interaction did not
appear to have an impact on the infants’ attachment security to their mothers, except when mothers were highly
insensitive (NICHD ECCRN, 1997).
In all of these studies, the quality of motherchild interaction and attachment security have been evaluated in
relation to the number of hours that the child spends in child care or the number of hours that the mother is
employed. However, it is significant that none of them has assessed the amount of time that the mother and
child actually spend together, and in the absence of empirical evidence, it is generally assumed that hours of
maternal employment serve as a proxy for the reduction in the amount of time spent in motherchild interaction
(Baydar, Greek, &Gritz, 1999). Contrary to this assumption, evidence from studies based on time-use diaries
and interviews has shown that maternal employment is related to a relatively small reduction in social
interaction and a larger reduction in physical care (Baydar et al., 1999; Hilton, 1990; Nock &Kingston, 1988;
Walker &Woods, 1976), with differences of less than 5 hours of care per week between employed and
nonemployed mothers (Douthitt, 1989; Sanik, 1990).
One limitation of these time-use studies is the assumption that time spent in mother-child interaction is, by
definition, “quality time” that will enhance children’s development (Bryant, 1992). However, large individual
differences exist in the quality of interaction when mothers and children do spend time together, and these
differences predict child outcomes in cognitive, linguistic, and socioemotional domains (e.g., Baumrind, 1989;
NICHD ECCRN, in press). Thus, it is important to measure directly the quality and quantity of mother-child
interaction.
It is also likely that there are individual differences in the extent to which mothers, regardless of employment
hours, optimize the time that is available for interacting with their infants. In some families, employed mothers
may make special efforts to spend high-quality time with their infants during nonwork hours or on the weekends,
whereas in other families, the stresses of multiple roles and responsibilities may leave mothers with very little
time or energy to devote to their infants when they are at home together (Hochschild, 1989; Rachlin, 1987).
Similarly, it is likely that some stay-at-home mothers focus on spending a lot of high-quality interaction time with
their children, whereas others are mostly present in the home while engaging in other primary activities (Baydar
et al., 1999; Bianchi, 2000; Nock &Kingston, 1988).
Some of the variance in the amount of time mothers and infants spend together may be due, in part, to
demographic factors. Maternal education, for example, is positively related to amount (e.g., Bryant &Zick, 1996;
Hill &Stafford, 1980) and quality (e.g., Clarke-Stewart, Gruber, &Fitzgerald, 1994; NICHD ECCRN, 1999) of
motherchild social interaction.
Another source of individual differences in the time mothers spend with their infants may be the mothers’
psychological characteristics. For example, maternal separation anxiety may positively affect the extent to which
employed mothers are motivated to spend time with their infants when they are not at work. In support of this
hypothesis, Bradley, Whiteside-Mansell, Brisby, and Caldwell (1997) found that greater maternal separation
anxiety was related to mothers’ having greater socioemotional investment in their children. Also, Fagan (1994)
found that among employed mothers, greater maternal separation anxiety was positively related to time spent
with their infants in on-site child-care settings.
Attitudes about employment also may affect the extent to which mothers spend quality time with their infants.
Mothers who believe that the consequences of maternal employment for children are relatively negative are less

10 February 2015 Page 2 of 12 ProQuest

likely to be employed and are less likely to view maternal employment as acceptable at younger child ages
(Greenberger, Goldberg, Crawford, &Granger, 1988). If employed mothers must spend long hours away from
their children despite negative attitudes about employment consequences, we would expect these mothers to
maximize the amount of time they spend with their children when they have the opportunity to be together.
Nock and Kingston (1988) have suggested that fathers may compensate for the decreased time spent by
employed mothers with their children, thereby reducing the potential negative effects of maternal employment
on child outcomes. However, both Sanik (1990) and Douthitt (1989) found that fathers’ hours of caring for their
children did not differ as a function of maternal employment, even though these hours have increased in the
past few decades. Although the present study focuses primarily on the mother-infant relationship, we also
sought to determine whether fathers’ involvement with their infants varied according to the time these infants
spent apart from their mothers, and the effects of both father involvement and mother-infant time on child
outcomes.
The following questions were addressed in the present study: Among families in which the study infants spent
more than 30 hours per week in child care, versus those in which child care was not used, (a) How do the
mothers compare in the amount of time spent in instrumental care and social interaction with their infants? (b)
How do the mothers compare in the quality of interaction? (c) Is the quality of mother-infant interaction related to
the amount of time they spend together? (d) Do mothers’ psychological characteristics and fathers’ involvement
differ by group, and are they related to the amount of time mothers spend with their infants? and (e) Do the
quantity and quality of maternal care and father involvement predict child outcomes at age 15 months?
METHOD
Participants
Data were analyzed from the NICHD Study of Early Child Care, a prospective longitudinal study of the effects of
child care on children’s development. Participants were recruited during the first 11 months of 1991 from
hospitals at 10 research sites that were located in or near Little Rock, Arkansas; Irvine, California; Lawrence,
Kansas; Boston, Massachusetts; Philadelphia, Pennsylvania; Pittsburgh, Pennsylvania; Charlottesville, Virginia;
Morganton, North Carolina; Seattle, Washington; and Madison, Wisconsin. During selected sampling periods,
all women giving birth in each hospital were screened. Mothers were excluded if they were giving the baby up
for adoption, had a known or acknowledged history of substance abuse, were under 18 years of age, did not
speak English, planned to move in the next year, or lived outside the area or in a neighborhood considered
unsafe for visits; mothers were also excluded if the baby was part of a multiple birth, was not discharged within
7 days of birth, or had a congenital disability (see NICHD ECCRN, 1999, for more details).
Of the 1,364 participating mothers, 1,171 completed at least one time-use interview when their infants were 7
months of age. However, the sample for the present paper was further reduced to 326 because it included only
(a) mothers who were married or partnered and lived in the same household as the spouse or partner; (b)
mothers who completed the time-use interview on two occasions-one weekday and one weekend day (and, if
the mother was employed, one of these days had to be a work day and the other a nonwork day); (c) mothers of
infants spending 0 hours in nonmaternal child care from birth to 6 months of age (At-Home group; n = 183) or
mothers of infants spending an average of 30 or more hours per week in child care from birth to 6 months (In-
Care group; n = 143). Fathers also participated in the study at 6 of the 10 sites. Among the 326 families, data
were available for 126 fathers (64 in the At-Home group and 62 in the In-Care group).
Demographic characteristics of the At-Home group, the In-Care group, and the remaining families whose data
were not included (n = 845) are shown in Table 1. Compared with the nonincluded mothers, the mothers in the
present report were significantly older (29.27 vs. 28.07 years), t(1,169) = 3.32, p = .001. The groups did not
differ in parental education, family income-to– needs ratio, number of children, child gender, or ethnicity.
None of the mothers in the At-Home group was employed or in school from birth through 6 months, and none of
the children in this group spent any time in nonmaternal child care. Most of the In-Care group mothers (n = 135)

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were employed or in school at least 30 hours per week (M = 40.42 10.34 hours), and their children were in child
care for a mean of 36.01 ( 4.78) hours per week.
Demographic Variables
When the infants were 1 month old, mothers were interviewed at home to obtain information about the mother’s
age and parents’ education; the infant’s gender, birth order, and ethnicity. The family income-to-needs ratio was
obtained at 6 months. The income-to-needs ratio is an index of family economic resources, with higher scores
indicating greater financial resources per person in the household. Family income (exclusive of welfare
payments) was divided by the poverty threshold, which was based on total family size and number of children
under 18 years of age.
Psychological Characteristics of Mothers
The mothers’ psychological characteristics were assessed during home visits when the infants were 1 and 6
months of age.
Maternal separation anxiety. The Maternal Separation Anxiety Scale is a 21-item questionnaire adapted from
Hock, Gnezda, and McBride (1983). Each item is rated on a 5-point Likert scale ranging from 1 (strongly
disagree) to 5 (strongly agree). The items assess the mother’s sadness, worry, and guilt about separation from
her infant; beliefs about the importance of maternal care and her infant’s preference for maternal care; and
beliefs about her infant’s ability to adapt to nonmaternal care. Cronbach’s alphas were .93 at both 1 and 6
months. An average score was computed across ages.
Attitudes about maternal employment. At the 1month home visit the mothers completed 11 items of the Beliefs
About the Consequences of Maternal Employment for Children (Greenberger et al., 1988). The scale, which
uses 6-point Likert ratings (1 = disagree very strongly to 6 = agree very strongly), yields Benefits and Costs
scores. A high score on the Costs subscale (Cronbach’s alpha = .88) reflects the belief that children are likely to
have problems if their mothers are employed (e.g., “Children are less likely to form a warm and secure
relationship with a mother who is working full time”).
Father Involvement in Caregiving
When the infants were 6 months old, fathers at 6 of the 10 study sites completed a set of questionnaires,
including one describing their caregiving activities with the study child (NICHD ECCRN, 2000). The 11
caregiving activities (which included items such as bathing, feeding, reading to the infant, attending to the infant
when crying) were rated on a 5-point scale (1 = partner’s job, 3 = we share equally, 5 = my job) and summed to
yield a total score for Father Involvement in Caregiving (Cronbach’s alpha = .77).

Quantity of Mother-Infant Interaction
Quantity of mother-infant interaction was assessed when the infants were 7 months old, using a telephone time-
use interview with the mother on two occasions-one describing the immediately prior weekday-workday
(Monday through Thursday) and the other, the prior weekend-nonwork day (Saturday or Sunday).
The interview is a chronological account of what the mother did during the entire 24-hour period beginning at 1
minute after midnight on the previous day. The mother identified (a) her primary activity, (b) activity beginning
and end times, (c) her location, (d) the infant’s location, and (e) any secondary activity. Activity codes included
Caring for Child (instrumental care, interaction, supervision or discipline, helping or teaching, organized outings,

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outdoor play, other child care), Paid Work, Household Activity, Travel, Personal Care, Education/Training,
Organizational Activities, Social Activity, Quiet Leisure.
The activity codes yielded two summary variables, computed separately for weekdays and weekends:
Instrumental Care consisted of the total amount of time per day that the mother engaged in instrumental care,
supervision or discipline, and other child care with the study child as either primary or secondary activities.
Social Interaction consisted of the total amount of time per day that the mother spent interacting, helping, or
teaching, and being on organized outings with the study child as primary or secondary activities.
The validity of short-term recall methods of time-use data collection has been demonstrated via comparison with
a variety of other methods (Juster &Stafford, 1985; see Robinson, 1999). Within the NICHD data set, validity
data were obtained at one of the sites by use of the Experience Sampling Method (Larson &Csikszentmihalyi,
1983) at 7 months of age for 48 families who were called 60 times over 4 weeks. The percentage of calls in
which the mother was interacting with the child correlated at r = .56 with the total amount of mother-child
interaction (instrumental care plus social interaction) assessed via the time-use calls.
Quality of Interaction
Sensitivity in the HOME. The Infant/Toddler Home Observation for Measurement of the Environment (HOME;
Caldwell &Bradley, 1984) was administered during the 6-month home visit. The HOME is a semistructured
interview/observational procedure in which a home visitor answers a set of binary questions based upon
maternal response to specific queries and makes observations of materials in the home and the mother’s
behavior toward the child. Factor analysis of the items on the HOME yielded two relevant factor scores, Positive
Involvement and Lack of Negativity. The former scale comprised six items assessing the extent to which the
mother was positively responsive and affectionate to her infant during the home visit. The latter scale comprised
five items measuring the extent to which the mother refrained from behaving in a negative manner toward her
infant (e.g., shouting, spanking, annoyance, restriction) during the visit. The two scale scores were summed to
produce a composite score for Sensitivity in the HOME.
Child Outcomes
The specific child outcomes were selected to broadly represent important areas of development at 15 months-
cognition, language, social engagement, and attachment security.
Bayley Mental Development Index. The Bayley Mental Development Index (MDI) (Bayley, 1969) is the most
widely used measure of cognitive developmental status for children in the first 2 years of life. The assessment
measures sensory perceptual acuity and discrimination; memory, learning, and problem solving; early verbal
communication; and the ability to form generalizations and classifications. The MDI was administered in a
laboratory playroom setting at 15 months of age by trained examiners.
MacArthur Communication Development Inventory. The Communication Development Inventory (CDI) (Fenson,
Dale, Reznick, Thai, &Reilly, 1991) assesses early language development via a 493-item inventory that was
completed by the mothers when their children were 15 months old. The infant version of the CDI includes a 396-
item vocabulary checklist on which the mother indicates which words her child uses and which words her child
understands. Separate percentile scores for vocabulary production and vocabulary comprehension were
computed.

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Child engagement. During a home visit, mothers were asked to have their infants play with ageappropriate toys
in three containers in a set order for 15 minutes. Mother-infant interaction was videotaped, and the tapes from
all sites were shipped to a central location for coding. A series of 4-point ratings was used to characterize the
behaviors of the mothers and infants separately. Two of the ratings of child behavior–child engagement and
positive mood-were summed to yield a child engagement composite. Cronbach’s alpha for the composite at 15
months was .58, and reliability was .74.
CONCLUSION
In summary, our results indicate that among mothers whose infants were in 30 or more hours per week of child
care, the “cost” in terms of reduced mother-infant interaction time was considerably less than expected, and the
quality of mother-infant interaction did not appear to be affected by the amount of time spent apart. It is likely
that these mothers attempted to compensate for time spent apart by focusing increased attention on their
infants during the weekend, and this was especially true if the mother was concerned about her separation from
the infant and the effects of her employment on the child. Fathers, as well, may have attempted to compensate
for maternal employment hours by being more involved with their infants.
Compared with prior maternal time-use studies, our investigation focused on a number of unique areas.
Namely, we addressed psychological predictors of the quantity of time mothers spent interacting with their
infants, the relation between quantity and quality of interaction, and the consequences for the infant’s
development of the quantity and quality of maternal care. Additionally, we identified the importance of
considering weekday and weekend time separately.
It is clear that the data in this report have provided a first step toward expanding the study of maternal time use,
but it is also clear that the results have raised additional questions that can be answered only in the context of
longitudinal in-depth research that includes more extensive time-use data and that includes both parents.
Perhaps the most important of these questions is the extent to which the quantity of parent-child interaction is
related to child outcomes over time and at older ages. Although time-use researchers have tended to assume
that parents who spend a lot of time with their infants are providing high-quality parenting that will promote
optimal development, our results suggest the need for careful consideration of the complex relations between
the quantity of interaction, the quality of parenting, and child outcomes.
Footnote
NOTE
Footnote
The authors are investigators in the NICHD Study of Early Child Care and acknowledge the generous support of
their time by the National Institute of Child Health and Human Development (Grants HD25447, HD25456,
HD27040, HD25451). The study is directed by a steering committee and supported by NICHD through a
cooperative agreement (UlO) that calls for scientific collaboration between the grantees and the NICHD staff.
The authors would like to thank the coinvestigators who worked with them on the design of the larger study, the
site coordinators and research assistants who collected the data, and the families and teachers who continue to
participate in this longitudinal study.
References
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AuthorAffiliation
CATHERINE L. BOOTH University of Washington
K. ALSION CLARKE-STEWART University of California-Irvine*
DEBORAH LOWE VANDELL University of Wisconsin**
KATHLEEN MCCARTNEY Harvard University***
MARGARET TRESCH OWEN University of Texas-Dallas****
AuthorAffiliation
Department of Family &Child Nursing, University of Washington, CHDD 106 South Building, Box 357920,
Seattle, WA 98195-7920 (ibcb@u.washington.edu).
AuthorAffiliation
*Department of Psychology and Social Behavior, University of California-Irvine, 3340 Social Ecology 11, Irvine,
CA 92697-7085.
**Department of Educational Psychology, University of Wisconsin, 1025 West Johnson Street, Room 467,
Madison, WI 53706.
AuthorAffiliation
***Harvard Graduate School of Education, Harvard University, 704 Larsen Hall, Appian Way, Cambridge, MA
02138.
****School of Human Development, University of Texas– Dallas, P 0. Box 830688, Mail Station GR 41,

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Richardson, TX 75083-0688.
Subject: Comparative studies; Mothers; Babies; Child care;
Publication title: Journal of Marriage and Family
Volume: 64
Issue: 1
Pages: 16-26
Number of pages: 11
Publication year: 2002
Publication date: Feb 2002
Year: 2002
Publisher: Blackwell Publishing Ltd.
Place of publication: Minneapolis
Country of publication: United Kingdom
Publication subject: Public Health And Safety, Matrimony, Education, Sociology, Children And Youth – About
Source type: Scholarly Journals
Language of publication: English
Document type: Feature
ProQuest document ID: 219764964
Document URL: http://nclive.org/cgi-
bin/nclsm?url=http://search.proquest.com/docview/219764964?accountid=11330
Copyright: Copyright National Council on Family Relations Feb 2002
Last updated: 2014-06-21
Database: ProQuest Central

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