PEDIATRICS Vol. 118 No. 2 August 2006, pp. e293-e298 (doi:10.1542/10.1542/peds.2005-2919)
ARTICLE |
Does Maternal Control During Feeding Moderate Early Infant Weight Gain?
a School of Psychology, Keele University, Keele, Staffordshire, United Kingdom
b School of Psychology, University of Birmingham, Edgbaston, Birmingham, United Kingdom
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONREFERENCES |
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OBJECTIVE. Our objective with this study was to examine whether observed maternal control during feeding at 6 months of age moderates the development of early infant weight gain during the first year of life.
METHODS. Sixty-nine women were observed feeding their 6-month-old infants during a standard meal. Mealtimes were coded for maternal use of controlling feeding behavior. All infants were weighed at birth and at 6 and 12 months of age, and weight gain was calculated from birth to 6 months and from 6 to 12 months. Weight scores and weight gain scores were standardized for prematurity, age, and gender.
RESULTS. Infant weight gain between 6 and 12 months of age was predicted by an interaction between early infant weight gain (birth to 6 months) and observed maternal control during feeding at 6 months. When maternal control was moderate or low, there was a significant interaction with weight gain from birth to 6 months in the prediction of later infant weight gain from 6 to 12 months, such that infants who showed slow early weight gain accelerated in their subsequent weight gain, and those with greater early weight gain decelerated. Conversely, when maternal control was high, infant weight gain followed the opposite pattern.
CONCLUSION. Maternal control of solid feeding can moderate infant weight gain.
Key Words: maternal control • infant weight • growth • observations
Abbreviations: SDS—SD score • ICQ—Infant Characteristics Questionnaire • FIS—Feeding Interaction Scale
Child weight is one of the most salient aspects of child health and can become concerning when children are either overweight or underweight. When children fail to gain sufficient weight, they can become malnourished, in many cases leading to associated cognitive problems.1 At the other extreme, excessive child weight gain can lead to obesity and the various medical problems that are associated with this increasingly common phenomenon, including cancer, cardiovascular disease, and type 2 diabetes.2,3
When faced with concerns about child weight gain or weight loss, assuming greater control over child feeding is a common strategy for many caregivers. When children are underweight, parents may pressure their children to eat greater amounts or types of foods, and when children are overweight, caregivers may encourage children to eat healthful foods and restrict the consumption of the amount or type of energy-dense foods.4,5 These types of feeding strategies tend to be correlated, with many caregivers controlling food intake using both restriction and pressure.6 In the short-term, these strategies may prove productive, temporarily producing the desired effects on food consumption and reinforcing their success and subsequent use. However, research suggests that the use of overcontrol when feeding ultimately is a counterproductive activity that can exacerbate the existing weight or feeding problem. Indeed, coercing, forcing, or pressuring children to eat has been linked with poor child self-regulation of intake7 and subsequent refusal and rejection of previously forced foods even in adulthood.8 Moreover, such strategies may condition children to find feeding itself an aversive experience, leading to conditioned food anxiety and avoidance.9 Similarly, restricting children from eating certain types of foods has been associated with increased preference for the withheld or restricted food.4,10 Ultimately, controlling feeding practices have been shown to predict poor responsiveness to internal cues of hunger and satiety. In particular, pressure to eat has been linked with child dietary restraint and emotional disinhibition with food, whereas restriction has been shown to predict external disinhibition,11 eating in the absence of hunger,12 and a more negative self-evaluation of eating.13
In summary, although previous research has established links among controlling feeding practices, child feeding, and weight,5,11,12 a lack of longitudinal and observational data precludes questions of cause, effect, and reliability. This study addresses these issues using a longitudinal and observational study that was initiated from birth.
Our aims with this study were to explore whether maternal use of control during feeding observations would moderate the relationship between early (birth to 6 months) and later (6–12 months) infant weight gain. It was hypothesized that infant weight gain between birth and 6 months would negatively predict weight gain from 6 months to 1 year when mothers are less controlling, indicating that infants "regress to the mean" in their weight.14,15 However, it was hypothesized that this relationship would be moderated by observed maternal use of control when feeding at 6 months, specifically, that mothers who are more controlling when feeding their infants would have infants who would show greater stability in their weight gain. This study also examined the relationships among infant temperament, gender, birth weight, and breastfeeding history with infant weight and maternal control to ensure that these factors did not confound the hypothesized relationship between weight gain and maternal control.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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After ethical permission from South Birmingham National Health Service Trust Ethics Committee, United Kingdom, women were recruited during pregnancy to take part in a longitudinal study to explore problems with infant feeding. The data reported here are from a subset of 69 dyads from a larger sample of 87 women recruited; the data reported here represent mothers who gave informed consent to be observed feeding their infants at 6 months of age and for their infants to be weighed at birth and at 6 and 12 months postpartum. The mean age of these women on recruitment to the study during pregnancy was 31.69 years (SD: 5.16). The sample was a nonclinical sample; no mothers disclosed that they had mental health problems or had been referred because of issues such as abuse or neglect, all infants were healthy with no congenital abnormalities or other medical conditions, and none had received a diagnosis of growth faltering (failure to thrive). One boy's weight was below the fifth centile at 1 year, but exclusion of this case did not alter any of the statistical findings. Not all infants were term, the mean age of gestation was 39.68 weeks (SD: 1.82; range: 34–42 weeks), but Pearson's 2-tailed correlations indicated that age of gestation was not significantly correlated with maternal use of control during feeding. Furthermore, infant weight scores were standardized to correct for prematurity.
Measures
Infant Weight
Infants were weighed at birth in the hospital and were weighed thereafter by the lead researcher at 
6 and 12 months of age. Infants were weighed naked with electronic scales, and weight in kilograms was converted into standardized z scores, also termed SD scores (SDSs), adjusting for infant gender and age. Birth weight standardization also was corrected for prematurity such that a child who was born at 38 weeks' gestation was considered to be –2 weeks of age rather than 0 weeks of age. The Child Growth Foundation reference curves package was used to compute all SDSs.16 The package was also used to compute weight gain scores on the basis of total weight gain across 2 time points: converting weight gain from birth to 6 months, and weight gain from 6 to 12 months into SDSs.
Breastfeeding
Mothers were asked whether they breastfed and, if so, for how long.
Infant Temperament
For assessment of infant temperament, at 6 months of age, all mothers completed the Infant Characteristics Questionnaire (ICQ).17 The ICQ assesses maternal perception of child fussiness-difficultness, adaptability, dullness, and predictability. The ICQ has been shown to have adequate factor structure, internal consistency, and test–retest reliability and is convergent with other questionnaire ratings of temperament.17
Observations
All mothers were observed feeding their infants solid foods at 6 months. Mealtimes were observed in the caregivers' homes, and feeding interactions were recorded using a video camera. Caregivers were asked to feed their infants as they normally would to provide as natural an example of feeding as possible. The video camera was placed in an unobtrusive position. Recording started when the mother first offered the infant food and continued until the food was removed. All mothers offered their infants the type of foods that they normally would use to feed, and disliked foods were not offered. The "nonverbal maternal behavior" scale (a measure of controlling maternal behavior) of the Feeding Interaction Scale (FIS) (D. Wolke, M. Sumner, Y. McDermott, and D. Skuse, University of Hertfordshire, unpublished instrument, 1987) was used to code maternal use of control during feeding interactions. The total FIS consists of 8 scales that assess maternal behavior, but for the purpose of this study, only 1 scale was used: maternal use of control during feeding. This scale depends on 1 rating of how much nonverbal control the caregiver asserts throughout the mealtime interaction, with the observer rating the mother within a range from not controlling (allowing the infant autonomy to control his or her own feeding while supervising the infant) to a very controlling caregiver (who is continuously forcing, offering, positioning, or distracting the infant to eat). This scale is negatively coded on a Likert scale from 1 to 9 and provides one total score, with 1 indicating the greatest control and 9 indicating the least controlling caregiver.
The FIS has clinical validity and has been used to assess mother–child feeding interactions and to diagnose feeding problems.18,19 All feeding interactions were coded by a researcher who was familiar with the coding procedure; 20% of the videotaped interactions were recoded by a second trained observer to ascertain interrater reliability. The intraclass correlation coefficient for this observed behavior was .784 (P < .001).
Statistical Analyses
After descriptive statistics, independent sample t tests and Pearson's 2-tailed correlations were used to assess whether infant gender, temperament, birth weight, and breastfeeding history were related to infant weight gain scores or to maternal use of observed control during feeding. Next, a Pearson's correlation was used to investigate the relationship between weight gain from birth to 6 months and weight gain from 6 to 12 months. Finally, the moderating role of controlling maternal behavior at 6 months was tested by examining the main effect and interaction effect of early infant weight gain (birth to 6 months) and controlling maternal behavior (at 6 months) in predicting weight gain from 6 to 12 months. The moderator effect is shown when the product term of the independent variable and moderator are significant when their main effects are controlled.20 The effects of the independent variable at various levels of the moderator were tested using simple slope analysis.21
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Descriptive Statistics
Means and SDSs for infant weight and weight gain during the first year of life are presented in Table 1. Mean infant SDS birth weight was 0.132 (approximately equivalent to a weight of 3.6 kg for a boy and 3.46 kg for a girl at birth). Mean infant weight at 6 months was 0.143 (equivalent to a weight of 8.18 kg for a boy and 7.6 kg for a girl at 6 months). At 1 year, mean infant SDS weight was 0.047 (representing a weight of 10.62 kg for a boy and 9.94 kg for a girl at 1 year). Table 1 also displays descriptive statistics for maternal use of controlling behavior; mean maternal control at 6 months was 5, which indicates that the mother primarily is involved in feeding the infant, with 1 or 2 instances of force-feeding, offering, or positioning. Fifty-one women breastfed their infants, and 18 exclusively bottle-fed. Of mothers who breastfed, the mean length of breastfeeding was 31.73 weeks (SD: 15.85). Thirty-one women were breastfeeding at the 6-month home visit.
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Because of previously identified gender differences in the use and consequences of controlling feeding practices,4,22 independent sample t tests were performed to establish whether mothers of male and female children differed in their use of control when feeding at 6 months or in their weight gain scores. Male and female children did not differ significantly according to their mother's use of control (t67 = –1.476, P > .05), weight gain from birth to 6 months (t67 = –0.376, P > .05), or weight gain from 6 to 12 months (t67 = 0.080, P > .05). Consequently, the 2 groups were homogenized for additional analysis.
An independent sample t test also was used to assess whether breastfeeding status (breastfed versus not breastfed) was associated with caregiver use of controlling behavior: breastfed infants did have caregivers who were less controlling at mealtimes (t67 = –2.208, P < .05; see Farrow and Blissett23 for additional details), but breastfed infants did not differ significantly from nonbreastfed infants with regard to their weight change scores from birth to 6 months (t67 = –0.074, P > .05) or 6 to 12 months (t67 = –0.600, P > .05). These findings suggest that although breastfeeding may be linked with maternal use of control when feeding, it did not confound any moderating relationship between infant weight gain and maternal control at mealtimes.
Next, Pearson's correlations were used to assess whether infant birth weight (not standardized for gestational age) was associated with maternal use of control at mealtimes or infant weight gain scores. Infant birth weight was significantly negatively associated with weight gain between birth and 6 months of age (r = –0.587, P < .01), indicating that lighter-born infants gained more weight between birth and 6 months (ie, infant weight self-regulation or regression toward the mean). However, infant birth weight was not significantly associated with gain between 6 and 12 months (r = 0.178, P > .05) and was not associated with caregiver use of control at mealtimes (r = 0.016, P > .05), suggesting that birth weight did not confound any relationship between maternal control and infant weight gain.
Because of the established links between child temperament and feeding problems,18 Pearson's correlations also were used to establish whether infant temperament was significantly correlated with maternal use of control during feeding or infant weight gain scores. Infant temperament was not significantly correlated with maternal use of control, infant weight, or weight gain scores (Table 2).
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Associations Between Infant Weight Gain From Birth to 6 Months and 6 to 12 Months
A Pearson's correlation was used to investigate the relationship between infant weight gain from birth to 6 months and infant weight gain from 6 to 12 months. The 2 variables were significantly negatively correlated (r = –0.382, P < .01), again indicating that infants self-regulated their weight.
Moderating Role of Maternal Controlling Behavior
Regression analyses were used to explore whether controlling maternal behavior at 6 months moderated the relationship between early (birth to 6 months) and later (6–12 months) infant weight gain. The interaction between early infant weight gain (birth to 6 months) and maternal control during feeding at 6 months was a significant predictor of later infant weight gain (6–12 months; ß = –.402, P < .001).
The significant interaction was investigated further using simple slope analyses. Slopes for the regression of early infant weight gain on later infant weight gain were computed at 3 levels of the moderator: the mean (moderate), 1 SD above the mean (high), and 1 SD below the mean (low) (Fig 1). The interaction between weight gain and maternal control was significant when the moderator was at the mean (B = –.177, P < .01) and 1 SD above the mean (B = –.525, P < .001), corresponding to low maternal control.
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Figure 1 indicates that when maternal control was moderate or low, infants seemed to regulate their own weight gain across the first year, with those with rapid early weight gain slowing down and those with slow early weight gain accelerating in their subsequent weight gain. However, when maternal control at 6 months was high, infant weight gain followed the opposite pattern and infants showed greater consistency in their weight gain (although the interaction was not significant when maternal control was high). When children showed slow weight gain from birth to 6 months and maternal control was high, children showed slower weight gain from 6 months to 1 year, compared with children whose mother was less controlling. Conversely, when children had high weight gain from birth to 6 months and maternal control was high, children showed greater weight gain in the latter part of the first year, compared with infants whose mother was less controlling.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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The aim of this study was to investigate the role of observed maternal control during feeding at 6 months as a moderator of the relationship between early (birth to 6 months) and later (6–12 months) infant weight gain. The data indicate that maternal control during feeding at 6 months of age significantly moderates the influence of early infant weight gain on later infant weight gain. Specifically, when maternal control was moderate or low, infants seemed to regulate their own weight gain across the first year, with those with rapid early weight gain slowing down and those with slow early weight gain accelerating in their subsequent growth. However, when maternal control at 6 months was high, child weight gain followed the opposite pattern and infants maintained consistency in their weight gain.
One interpretation of these findings is that mothers of children with low weight gain are using controlling feeding practices to attempt to increase infant weight, whereas those with high early infant weight gain are attempting to slow their infants' weight gain. If so, then these strategies seem to be counterproductive and less successful than not controlling food intake during feeding. This conclusion concurs with other evidence that has found that controlling child food intake is counterproductive; for example, pressuring children to eat is linked with child food refusal and underweight, whereas restriction is associated with greater intake and child overweight,4,5,10 even in longitudinal studies that controlled for earlier child weight.24 However, these findings are the first to suggest that maternal control during feeding may have this adverse effect on weight gain as early as 6 months of infant age. Most research in this field is conducted with children aged 5 years,12,25 when the nature of cause and effect in the relationship between child weight and maternal control is even more difficult to disentangle from other influential factors.
When allowed to regulate their own feeding and food intake, infants seem to self-regulate, with those who are born light gaining more weight than those who are born heavy.14,15 For many caregivers, it can be distressing to have a child who is born heavy but then begins to lose weight; moreover, a child who is born light and rapidly moves up the centiles can lead to concern for some caregivers who are worried about childhood obesity. Feeding in the first year of life necessitates a great deal of parental control given that young infants are incapable of feeding themselves independently, yet the data are compatible with the suggestion that in normal circumstances, infants develop best when given as much autonomy as possible. The data reported here may suggest that some caregivers are responding to their infants' regulation by asserting greater control during feeding. Ironically, taking control from the infant over food consumption is a counterproductive activity, which may inhibit infants' attendance to their internal cues of hunger and satiety, leading to the converse to its desired effect. Not only may the use of greater control interfere with the infants' natural weight trajectory during the first year of life, but also the longer term effects may be disinhibited eating, eating in the absence of hunger, food refusal, and later child obesity or underweight.5,11,12
On the basis of these data, it may be premature to conclude that maternal control is interfering with infant self-regulation; this study has many limitations, and additional research in this field is needed to explore and interpret these findings in more detail and to investigate other factors that may determine whether infants gain, lose, or maintain a consistent weight trajectory. For example, this research relies on only 1 observation of maternal feeding behavior, which may not be an accurate reflection of actual maternal control during feeding, and additional research should replicate these findings using multiple observations of maternal feeding behavior. It also is important to note that this study featured a nonclinical sample of mother–child dyads; therefore, these results and their implications should not be generalized to samples of infants who are faltering in their growth or have been referred because of parental abuse or neglect. Additional longitudinal research is necessary to explore how other factors that are known to influence maternal use of controlling feeding strategies may interact further with these variables, such as maternal dietary restraint, fruit and vegetable consumption, history of breastfeeding, and maternal ethnicity.26–28 Of course, intrinsic biological characteristics of the infant will influence his or her weight gain and determine regulation or consistency in infant weight, and such factors need to be integrated into additional research that examines the role of parental control of feeding in the determination of weight gain in infancy and childhood. Moreover, we assumed that caregivers are controlling their children's food intake in response to their perceived weight gain, but additional research could interview parents about their motivation for using controlling feeding practices. Finally, a focus on prenatal measures of maternal feeding attitudes may help to elucidate further the causal mechanisms that are at work in this relationship. Overall, this study suggests that in normal samples of infants, the promotion of infant autonomy in feeding may be advantageous in appropriate regulation of weight during the first year of life.
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ACKNOWLEDGMENTS |
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This work was completed while Dr Farrow was based at the University of Birmingham.
We thank the mothers who took part in this research, without whom this study would not have been possible.
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FOOTNOTES |
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Accepted Feb 16, 2006.
Address correspondence to Claire Farrow, PhD, School of Psychology, Dorothy Hodgkin Building, Keele University, Keele, Staffordshire ST5 5BG, United Kingdom. E-mail: c.v.farrow{at}psy.keele.ac.uk
The authors have indicated they have no financial relationships relevant to this article to disclose.
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PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics
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