Feeding, like other sensorimotor skills, is a developmental skill that matures during the first two years of life. It is a highly complex sensorimotor process with developmental stages based on neurological maturation and experiential learning.1 However, feeding, unlike other sensori-motor skills, is heavily reliant on internal incentive or motivation to initiate ingestion, and is essential for survival of the newborn. Thus, the act of feeding is highly charged emotionally for the mother, whose primary responsibility, as viewed by the family, society and culture around her, is to ensure the early growth and well being of her child. Therefore, from the very beginning the mother-infant feeding relationship is influenced by physiologic as well as interactional forces at multiple levels.2
When feeding skills are intact and appetite is robust, feeding times, and later on, mealtimes are a source of pleasant socialisation resulting in adequate nutrient intake and good growth. Demanding food at regular intervals, sucking, eating and drinking with good rhythm, trying new food tastes or textures, and expressing satisfaction at the end of feeding are all considered good feeding behaviours by family and society. These pro-feeding behaviours invite praise and positive feeding interactions and thus reinforce the feeling of self-mastery in the young child and promote continued food acceptance and independent feeding behaviours.
However, when feeding skills are impaired (e.g.: poor oral-motor skills, taste and texture sensitivities) and or poor appetite (inadequate hunger), they manifest themselves in problematic feeding behaviours such as not signalling hunger, sucking or eating excessively slowly, gagging, and not bringing food to the mouth.3-7 In addition, associative conditioning to painful gastrointestinal cues is particularly powerful in young infants and this conditioning often manifests itself in problematic feeding behaviours.8,9 Temperamental characteristics and regulatory capacities of the infant may further modulate feeding behaviours.10,11 Maternal attempts at increasing her infant’s nutrient intake by feeding more frequently or longer duration tend to result in stressful feeding experiences for both.12 While these efforts may work well initially for maintaining good weight gain, they tend to become ineffective and maladjusted mealtime interactions and behavioural mismanagement prevail.2,13-15 Maternal and family characteristics and societal expectations about the size of the young child and the type of food eaten further influence an already stressful feeding relationship.16,17
Feeding difficulties are one of the most common developmental disturbances in otherwise healthy infants and young children, often resulting in poor growth. Although an estimated 25%- 50% of children experience transient feeding problems under two years of age,18,19 most feeding issues resolve by the end of early childhood. However, an estimated 3-10% of children present with more severe forms of feeding problems which put children at risk for impaired growth, chronic illnesses and behavioural developmental problems.20 As well, a large percentage of children with special needs, children with developmental disabilities and children born prematurely have severe and chronic feeding problems where families need support in resolving the feeding issues.21-23 At the clinical level, the mother (and her paediatrician) is often not aware of the underlying reasons for problematic feeding behaviours. Thus, the mother’s reactions to a poor feeder may be exposed to covert or overt family criticism, which often lead to internal doubt about her own ability to nurture.4 At the policy level, there is a lack of education of professionals and young parents about feeding as a highly complex developmental skill, motivated by hunger and conditioned by parental reactions. Furthermore, professionals are still not trained to recognize that when either feeding skills or motivation or both are impaired, problematic feeding behaviours, stressed mealtime interactions and family conflicts are likely to result.
Earlier cross sectional clinical studies examined the relationship between feeding difficulties and attachment, maternal characteristics, family dynamics24 and feeding practices.24-30 These studies were conducted prospectively, that is, after the children were diagnosed with poor growth. Several observational studies focused on feeding interactions and problematic feeding behaviours.31,32 The development of feeding and patterns of food acceptance have been studied by numerous psychologists.33-36 More recently, few researchers started to focus on possible pathophysiology (heart rate variability, hormonal balance) of poor growth and problematic feeding behaviours.37-39 Other studies were conducted in the context of primarily behavioural interventions for problematic feeding behaviours in medically ill and very premature infants.40-43
Key Research Questions
The extensive research in the area of feeding problems and poor growth can be divided along the following three research questions:
- How do maternal (family) characteristics (cognitive abilities, personality disorders, psychological status and early attachment history) influence feeding behaviours and growth?
- How do infant characteristics (feeding skills, appetite, temperament and other physiological characteristics) influence feeding behaviours, mealtime interactions and growth?
- How effective are behavioural and other forms of intervention for severe problematic feeding behaviours in medically ill infants?
Recent Research Results
Only questions 2 and 3 will be summarised here. With a focus on infant characteristics, studies have shown that feeding problems often co-occur with sleeping and behavioural disturbances (irritability, poor self-calming and intolerance to change), suggesting that these are symptoms of a common underlying constitutional “regulatory disorder” in infants and young children.44,45 In a large whole-population survey of children’s growth and development, a significant portion (36%) of the 47 children identified with failure to thrive at one year of age were found to have oral motor difficulties, suggesting that these children were biologically more vulnerable to poor eating from birth.46 Another study showed that young infants with gastroesophageal reflux were significantly more likely to have delay in their feeding skills and readiness behaviour for solids than controls.47 In a prospective study of a group of healthy term infants (n=330), infants with inefficient sucking, as measured by tracings on a polygraph, at one week and two months were significantly more likely to have mothers with greater effort at feeding than infants with efficient sucking.14
A number of studies have shown that children under 3 to 4 years of age eat primarily in response to appetite or hunger cues, whereas older children’s eating are influenced by a variety of environmental (extra food available) and social factors.48,49 As well, children with poor growth were observed to refuse offered food more often and fed themselves significantly less often than controls.50 In terms of the third question, the literature reflects the reality that presently we are better at identifying factors contributing to feeding problems at any level of severity than treating them.28,51,52 Treating feeding problems at the primary or secondary level, while desirable, is not always available for parents.53 Treating feeding disorders associated with severe medical illnesses, developmental disabilities and gavage feedings requires the collaboration of multidisciplinary teams for successful outcome.54-59 Lastly, studies have shown that appetite stimulating medications result in good weight gain, and thus making intervention more efficacious.60-62
Understanding feeding behaviours requires the knowledge of feeding as a developmental skill that matures over time and is reliant on hunger (appetite) cues and experiential learning. Whereas feeding skills are well established by two years of age, hunger cues shift from primarily internal to external (family, school and societal) control only by 4-5 years. Thus, although initially problematic feeding behaviours tend to be reactions to internal cues, these behaviours can become conditioned to external (coaxing parents) and societal cues. Medical illnesses, prematurity and developmental disorders further interfere with the development of normal feeding behaviours.
In order to help identify feeding problem, a number of feeding scales have been devised,63-65 but rarely used for assessment or treatment outcome. Yet, early behavioural intervention can play an important role in normalizing feeding behaviours and mealtime interactions, which in turn help promote independence and other self-help skills in the child. Most recently, an easy and short screening tool was developed for detecting problematic feeding behaviours in primary care offices, allowing early referral to appropriate feeding clinics.66
Implications for Policy and Services
The major findings from this updated summary continue to be that the physiological make up of the infant, medical illnesses, developmental disabilities and parental responses all play an important role in the dynamic relationship in which problematic feeding behaviours develop. This finding has several implications for policy and services in the area of impaired feeding behaviours and poor growth. The implications for policy and services include:
- At the primary care level, the use of easy to administer feeding scales for earlier detection and thus, treatment of feeding problems should be advocated by paediatric and other primary care professionals’ associations.
- The creation of multidisciplinary feeding clinics with the mandate of addressing feeding disorders should be mandated in major hospital settings. These feeding programs need to be easily accessible to parents, where effective behavioural intervention and preventive strategies may be implemented in the early stages of reported difficult feeding behaviours.
- The training of experts in the field of feeding disorders, which should include training in the behavioural, developmental and interactional components of feeding at college and university levels should be advocated.
- Further research into treatment outcomes for children with feeding disorders need to be strongly encouraged.
- Stevenson RD, Allaire JH. The development of normal feeding and swallowing. Development and behavior: The very young child. Pediatr Clin North Am 1991;38:1439-1453.
- Ramsay M. Les problèmes alimentaires chez les bébés et les jeunes enfants. Une nouvelle perspective. PRISME. 1999; 30:10-27.
- Milla PJ. Feeding, tasting and sucking. In Walker WA, Durie P, Hamilton J, Walker-Smith J, Watkins J, eds. Pediatric gastrointestinal disease: pathophysiology, diagnosis, management. Philadelphia, PA: DC Decker; 1991:217- 223.
- Ramsay M. Feeding disorder and failure to thrive. Child Adolesc Psychiatr Clin North Am.1995;4:605-616.
- Reau NR, Senturia YD, Lebailly SA, Christoffel KK. Infant and toddler feeding patterns and problems. Normative data and a new direction. J Dev Behav Pediatr.1996;17:149-153.
- Jacobi C, Agras WS, Bryson S. Hammer LD. Behavioral validation, precursors and concomitants of picky eating in childhood. J Am Child Adolesc Psychiatr. 2003;42:76-84.
- Ramsay M, Gisel EG, Boutry M. Nonorganic failure to thrive: A growth failure secondary to feeding skills disorder. Dev Med Child Neurol. 1993;35:285-297.
- Davidson TL. Pavlovian occasion setting: a link between physiological change and appetitive behavior. Appetite. 2000;35:271-272.
- Hamilton AB, Zeltzer LK. Visceral pain in infants. J Pediatr.1994;125:S95-102.
- Harris G, Blissett J, Johnson R. Food Refusal Associated with Illness. Child Psych & Psychiatr. Review.2000;5:148-156.
- DeGangi GA, Porges SW, Sickel RZ, Greenspan SI. Four-year follow-up of a sample of regulatory disordered infants. Infant Men Health J. 1993;14:330-343.
- Ferguson A, Blaymore Bier LA, Cucca J, Andereozzi L, Lester B. The quality of sucking in infants with colic. Infant Men Health J. 1995;17:161-169.
- Ramsay M, Gisel EG. Neonatal sucking and maternal feeding practices. Dev Med Child Neurol.1996;38:34-47.
- Ramsay M, Gisel E, McCusker J, Bellevance F, Platt R. Infant sucking ability, nonorganic failure to thrive, maternal characteristics and feeding practices: A prospective cohort study. Dev Med Child Neurol. 2002; 44:405-414.
- Budd KS, McGraw TE, Farbisz R, Murphy TB, Hawkins D, Heilman N, Werle M, Hochstadt NJ. Psychosocial concomitants of children's feeding disorders. J Pediatr Psychol. 1992;17:81-94.
- Farrow C, Blissett J. Maternal cognitions, psychopathologic symptoms and infants temperament as predictors of early infant feeding problems: A longitudinal study. Int. J. Eat Disord. 2006;38:128-134.
- Knaapila A, Tuorila H, Silventoinen K, Keskitalo K, Kallela M, Wessman M, Peltonen L, Cherkas LF, Spector TD, Perola M. Food neophobia shows heritable variation in humans. Physiology and Beh. 2007;91:573-578.
- McDermott BM, Mamun AA, Najman JM, Williams GM, O'callaghan MJ, Bor W. Preschool children perceived by mothers as irregular eaters: Physical and psychosocial predictors of a birth cohort study. J Devel. Behav Pediat. 2008: 29:197-205.
- Carruth BR, Zeigler PJ, Gordon A, Barr SI. Prevalence of picky eaters among infants and toddlers and their caregivers’ decisions about offering a new food. Am. Dietetic Assn. 2004;104:S57-S64.
- Corbett SS, Drewett RF. To what extent is failure to thrive in infancy is associated with poorer cognitive development. A review and meta-analysis. J Child Psychol Psychiatr. 2004;45:641-654.
- Lenscheid TR. Behavioral treatments for pediatric feeding disorders. Behav Modif. 2006;30:6-23.
- SJ, Harris G, Blissett J. Tube feeding in infancy: Implications for the development of normal eating and drinking skills. Dysphagia. 2005;20:46-61.
- Cerro N, Zeunert S, Simmer KN, Daniels LA. Eating behaviour of children 1.5-3.5 years born preterm: Parents’ perceptions. J Paediatr Child Health. 2002;38:72-78.
- Piwoz EG, Black RE, Lopez de Romana G, Creed de Kanashiro H, Brown KH. The relationship between infants’ preceding appetite, illness, and growth performance and mothers’ subsequent feeding practice decision. J Soc Sci Med. 1994;9: 851-860.
- Benoit D. Failure to thrive and feeding disorders. In CH Zeanah, Jr. (Ed.): Handbook of infant mental health. New York: Guilford Press; 1993. p 317-331.
- Galler JR, Harrison RH, Biggs MA, Ramsey F, Forde V. Maternal moods predict breastfeeding in Barbados. Dev Beh Pediatr.1999;20: 80-87.
- Polan HJ, Kaplan MD, Kessler DB, Schindledecker R, Mewmark M, Stern D, Ward MJ. Psychopathology in mothers of infants with failure to thrive. Infant Men Health J.1991;12:55-64.
- Ward MJ, Kessler DB, Altman SC. Infant attachment in children with failure to thrive. Infant Men Health J. 1993;14:208-220.
- Lindberg L, Bohlin G, Hagekull B, Thurnström M. Early food refusal: Infant and family characteristics. Infant Men Health J. 1994;15:262-277.
- Parkinson NK, Drewett RF. Feeding behaviour in the weaning period. J Child Psychol. 2001;42:971-978.
- Lindberg L, Bohlin G, Hagekull B. Interactions between mothers and infants showing food refusal. Infant Ment Health J. 1996; 17:334-347.
- Stein A, Woolley H, Cooper SD, Fairburn CG. An observational study of mothers with eating disorders and their infants. J Child Psychol Psychiatr.1994;35:733-748.
- Birch LL, Gunder L, Grimm-Thomas, Laong DG. Infants’ consumption of a new food enhances acceptance of similar foods. Appetite.1998;30:283-295.
- Birch LL. Development of food acceptance patterns. Dev Psychol. 1990;26:515-519.
- Beauchamp GK, Mennella JA. Flavor perception in human infants. Developmental and functional significance. Digestion. 2001;83S:1-6.
- Coulthard H, Harris G, Emmett P. Delayed introduction of lumpy foods to children during the complementary feeding period affects child’s food acceptance and feeding at 7 years of age. Maternal & Child Nutr. 2009;5:75-85.
- Shaoul R, Kessel A, Toub, E, Lanir A, Glazer O, Jaffe M. Leptin and cytokines levels in children with failure to thrive. J Pediatr Gastroenter Nutr. 2003;7: 487-491.
- Steward DK, Moser DK, Ryan-Wenger NA. Biobehavioral characteristics of infants with failure to thrive. J Pediatr Nursing. 2001;16(3):162-171.
- Tannenbaum GS, Ramsay M, Martel C, Samia M, Zygmuntowicz C, Porporino M, Ghosh S. Elevated circulating acylated and total ghrelin concentrations along with reduced appetite scores in with failure to thrive. Pediatr. Res. 2009;65:569-573.
- Babbitt RA, Hoch RA, Coe DA, Cataldo MF, Kelly KJ, Stackhouse C, Perman JA. Behavioral assessment and treatment of pediatric feeding disorders. J Dev Beh Pediatr. 1994;5:278-291.
- Burklow KA, Phelps AN, Schultz JR, McConnell, Rudolph C: Classifying complex pediatric feeding disorders. J Pediatr Gastroenter Nutr. 1998;27:143-147.
- Werle MA, Murphy TB, Budd KS. Treating chronic food refusal in young children: Home-based parent training. J Appl Beh Anal. 1993;26:421-433.
- Burmucic K, Trabi T, Deutschmann A, Scheer PJ, Dunitz-Scheer M. Inpatient tube weaning in children with long-term feeding tube dependency: A retrospective analysis. Infants Men Health J. 2010; 31:664-681
- St.James-Roberts I, Plewis I. Individual differences, daily fluctuations, and developmental changes in amounts of infant waking, fussing, crying, feeding, and sleeping. Child Dev. 1996;67:2527-2540.
- Wolke D, Gray P, Meyer R. Excessive infant crying: A controlled study of mothers helping mothers. Pediatrics. 1994;94:322-334.
- Reilly SM, Skuse DH, Wolke D, Stevenson J. Oral-motor dysfunction in children who fail to thrive: organic or non-organic. Dev Med Child Neurol.1999;41:115-122.
- Mathisen B, Worrall L, Mase; J, Wall C, Shepherd RW. Feeding problems in infants with gastro-oesophageal reflux disease: a controlled study. J Paediatr Child Health.1999;35:163-169.
- Fisher JO, Birch LL. Eating in the absence of hunger and overweight in girls from 5 to 7 year of age. Am J Clin Nutr. 2000;76: 226-231.
- Rolls BJ, Engell D, Birch LL. Serving portion size influences 5-year-old but not 3-year-old children’s food intakes. J Am Diet Assoc. 2000;100:232-234.
- Drewett RF, Mambwe K-H, Wright C. Feeding behaviour in young children who fail to thrive. Appetite. 2003;40:55-60.
- Wright C, Birks E. Risk factors for failure to thrive: a population-based survey. Child:Care, Heath Dev. 2000;26:5-16.
- Field D, Garland M, Wiliams K. Correlates of specific childhood feeding problems. J. Pediatr Child Health. 2002;39:299-304.
- Hofacker NV, Papousek M. Disorders of excessive crying, feeding and sleeping: The Munich interdisciplinary research and intervention program. Infant MenHealth J. 1998;9:180-201.
- Williams KE, Field DG, Seiverling L. Food refusal in children: review of the literature. Res Dev Disabil. 2010; 31:625-633.
- Mason SJ, Harris G, Blissett J. Tube feeding in infancy: Implications for the development of normal eating and drinking skills. Dysphagia. 2005;20:46-61.
- Byars KC, Burklow KA, Ferguson K, O'Flaherty T, Santoro K, Kaul A. A multicomponent behavioral program for oral aversion in children dependent on gastrostomy feedings. J Pediatr Gastroentr & Nutri. 2003;37:473-480.
- Kindermann A, Kneepkens CM, Stok A, van Dijk EM, Engels M, Douwes AC. Discontinuation of tube feeding in young children by hunger provocation. J Pediatr.Gastroentr & Nutri. 2008;47:87-91.
- Garro A, Thurman SK. Kerwin ML E, Ducette JP. Parent/caregiver stress during pediatric hospitalization for chronic feeding problems. J Pediatr Nursing. 2005;20:268-275.
- Greer AJ, Gulotta CS, Masler EA, Laud RB. Caregiver stress and outcomes of children with pediatric feeding disorders treated in an intensive interdisciplinary program.J Pediatr Psychol. 2008;33:612-620.
- Al-Yaarubi S, Ramsay M, Rodd C. Megesterol acetate promotes euglycemia and appetite in a child with persistent hyperinsulimenic hypoglycemia. Acta Paediatrica. 2004;93:422-423.
- Blissett J, Harris G, Kirk J. Effect of growth hormone therapy on feeding problems and food intake in children with growth disorders. Acta Paediatrica. 2000;89:644-649.
- Homnick DN, Homnick BD, Reeves R, Marks JH, Pimentel RS, Bonnema SK. Cyproheptadine is an effective appetite stimulant in cystic fibrosis. Pediatric Pulmonol, 2004;8:129-134.
- Archer LA. Rosenblaum PL, Streiner DL. The children’s eating behaviour inventory: Reliability and validity results. J Pediatr Psychol. 1991;16:629-670.
- Crist W, Napier-Phillips. Mealtime behaviours of young children: A comparison of normative and clinical data. J Dev Beh Pediatr. 2001;22:279-286.
- Wardle J. Guthrie C, Sanderson S, Rapoport L. Development of the Children’s Eating Behaviour Questionnaire. J Child Psychol Psychiatr. 2001;42:963-970.
- Ramsay M, Martel C, Porporino M, Zygmuntowicz, C. The Montreal Children’s Hospital Feeding Scale: A brief bilingual screening tool for identifying feeding problems. Paediatr Child Health. 2011;16:147-151.
How to cite this article:
Ramsay M. Feeding skill, Appetite and Feeding Behaviours of Infants and Young Children and Their Impact on Growth and Psychosocial Development. In: Tremblay RE, Boivin M, Peters RDeV, eds. Faith MS, topic ed. Encyclopedia on Early Childhood Development [online]. https://www.child-encyclopedia.com/child-nutrition/according-experts/feeding-skill-appetite-and-feeding-behaviours-infants-and-young. Updated: September 2013. Accessed December 11, 2023.Text copied to the clipboard ✓