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Communicating hunger and satiation in the first 2years oflife: a systematic review
Janet McNally*, Siobhan Hugh-Jones*, Samantha Caton†, Carel Vereijken‡,Hugo Weenen‡ and Marion Hetherington**Institute of Psychological Sciences, University of Leeds, Leeds, UK, †School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK, and‡Danone Nutricia Research, Utrecht, Netherlands
Abstract
Responsive feeding has been identified as important in preventing overconsumption by infants. However, thisis predicated on an assumption that parents recognise and respond to infant feeding cues. Despite this,relatively little is understood about how infants engage parental feeding responses. Therefore, the aim of thissystematic review was to identify what is known about infant communication of hunger and satiation andwhat issues impact on the expression and perception of these states. A search of Medline, CINAHL, Webof Science, PsycINFO, Science Direct and Maternal and Infant care produced 27 papers. Eligibility criteriaincluded peer reviewed qualitative and/or quantitative publications on feeding behaviours, hunger, andsatiation/satiety cues of typically developing children in the first 2 years of life. Papers published between1966 and 2013 were included in the review. The review revealed that feeding cues and behaviours are shapedby numerous issues, such as infants’ physical attributes, individual psychological factors and environmentalfactors. Meanwhile, infant characteristics, external cues and mothers’ own characteristics affect how feedingcues are perceived. The existing literature provides insights into many aspects of hunger and satiation ininfancy; however, there are significant gaps in our knowledge. There is a lack of validated tools for measuringhunger and satiation, a need to understand how different infant characteristics impact on feeding behaviourand a need to extricate the respective contributions of infant and maternal characteristics to perceptions ofhunger and satiation. Further research is also recommended to differentiate between feeding driven by likingand that driven by hunger.
Keywords: infant feeding, hunger, satiation, behaviour, cue, communication.
Correspondence: Janet McNally, Institute of Psychological Sciences, University of Leeds, Leeds LS2 9JT, UK. E-mail: psjem@leeds.ac.uk
Introduction
Childhood obesity is prevalent in developed countries(Ogden et al. 2012; Wang & Lobstein 2006), andresearch has focussed on factors that might increaseobesity risk in children. Some of the factors identifiedthus far include parental body mass index (BMI),birthweight, early adiposity, weight gain during the firstyear of life and maternal feeding practices (Dev et al.2013; Reilly et al. 2005).
Several reviews indicate that maternal feedingpractices may increase obesity risk by influencing theearly entrainment of appetite control (De Lauzon-Guillain et al. 2012; Disantis et al. 2011; Hurley et al.2011). However, the precise mechanisms linking feeding
practices and childhood obesity remain unclear.DiSantis et al. (2011) proposed a theoretical role formaternal feeding ‘responsiveness’ in infant and childoverweight. ‘Responsive’ mothers are sensitive to hun-ger and satiation cues and respond to these appropri-ately, while discordant maternal responses are aproposed risk factor for obesity. Worobey et al. (2009)found lower maternal sensitivity to feeding cues at6months predicted infant weight gain between 6 and12months. Hurley et al. (2011) also found two typesof discordant response, restrictive feeding and indulgentfeeding, to be associated with a high BMI in infantsand young children. Meanwhile, DiSantis et al. (2011)suggested that a third kind of discordant response,maternal pressure to eat, may also increase obesity risk.
© 2015 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd. Maternal & Child Nutrition (2016), 12, pp. 205–228 205
DOI: 10.1111/mcn.12230
Review Article
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduc-tion in any medium, provided the original work is properly cited.
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Evidence for the latter view is mixed as Farrow &Blissett (2008) found pressure to eat at 1year to beassociated with lower weight at 2years. However,Farrow & Blissett (2006) found infants with high weightgain in the first 6months whose mothers exhibited pres-sure to eat continued on this trajectory between 6 and12months. In addition, Lumeng et al. (2012) found as-sertive prompts to eat and maternal intrusiveness to beassociated with higher adiposity in toddlers. Poorresponsiveness to satiation cues in the form ofpressure to eat may therefore also affect obesity risk.
Notwithstanding reported associations betweenmaternal responsiveness and infant adiposity, thedirection of causality between these remains unclear.Overfeeding may arise from insensitivity to fullnesscues or the use of food to settle fractious infants(Worobey et al. 2009; Redsell et al. 2010). Restric-tive feeding practices may also play a role by in-creasing the desirability, and consequentconsumption, of restricted foods (Dev et al. 2013).Importantly though, mothers may simply beresponding to their child’s appetite (Webber et al.2010a) as some infants have a more avid appetitethan others (Agras et al. 1990). In turn, mothersmay restrict intake for children they perceive toover-eat or may pressure children with small appe-tites to eat more (Webber et al. 2010b). There istherefore a need to better understand the issues thataffect interpretations of and responses to infantfeeding cues in order to develop interventions toprevent overfeeding. The aim of the current reviewwas to consider the evidence regarding what infantscommunicate during meals and what parents
respond to. Specifically, the review aimed to iden-tify the following:
1. How hunger and satiation are expressed in infantsand toddlers.
2. The issues that impact on the expression andperception of infant feeding cues.
3. How hunger and satiation behaviour can bedifferentiated fromeating driven by the hedonic fea-tures of food.
Method
Search strategy
An initial scoping exercise was conducted to establishwhether reviews had been completed previously on in-fant feeding cues. The Cochrane Systematic ReviewDatabase was searched followed by Medline,CINAHL, Web of Science, PsycINFO, Science Directand Maternal and Infant care. The scoping exercisewas also used to generate search terms and synonymsand to establish the utility of the databases for thesearch. Final keyword search terms appear in Table 1.
Keyword searches were conducted up to January2014. Where databases offered combined keywordand subject heading search options (Medline, Maternaland Infant Health and PsycINFO), search terms (in-fant and feeding) were mapped to subject headings.Following keyword and combined keyword and sub-ject heading searches, results were refined by apply-ing initial limiters: English language, full text, peerreviewed, human and child.
Key messages• Hunger cues are easier to perceive by mothers than satiation cues, and feeding cues are easier to interpret as chil-dren grow older.
• Infant feeding cues are diverse and highly variable across and within individuals being influenced by many issuesincluding age, sex, genotype, developmental maturity and feeding method.
• Feeding interactions are dyadic in nature, and both infant characteristics (age, sex and temperament) and maternalcharacteristics (e.g. body mass index) may affect how feeding cues are perceived.
• There is a need to develop methods for measuring infant hunger and satiation and for discriminating feeding drivenby hunger from that driven by liking. Additional research is also recommended regarding the impact of differentinfant characteristics on feeding behaviour and of different maternal and infant characteristics on perceptions ofhunger and satiation.
206 J. McNally et al.
© 2015 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd. Maternal & Child Nutrition (2016), 12, pp. 205–228
Results
The study selection process is outlined in Fig. 1; 5635articles were returned. Their titles were screened by thefirst author according to the inclusion and exclusioncriteria (Table 2), and irrelevant papers were discarded(n=5515). Duplicate and review articles were thenremoved (n=35). The abstracts of the remaining articles(n=85) were screened for relevance, and exclusion andinclusion criteria were applied resulting in 50 articlesbeing discarded.
Of the remaining 35 articles, only 34 were fully accessi-ble. These were read in full, and those not fulfilling
inclusion and exclusion criteria were discarded (n=17).A reference list search and a citation search wereconducted for the remaining 17 articles. From these, afurther 13 articles were obtained that met theinclusion/exclusion criteria (Table 3). The remaining 30articles were subjected to quality assessment. Thosescoring below 11 on the 22 point scale were removed,and a final 27 articles were selected.
Quality assessment of studies
In the final stage of selection, articles were rated forquality using a tool developed by Moore (2012). Thetool was selected on its suitability for assessing both qual-itative and quantitative papers and non-interventionstudies. Quality ratings were subjected to inter-rater reli-ability analysis using a non-fully crossed design; themainauthor rated all papers, while second authors each rateda different subset of papers. A random sample of 14papers was selected for the intraclass correlation analy-sis. A high level of inter-rater agreement was found
Fig. 1. Systematic review selection process.
Table 1. Final search terms
(Infan* OR baby OR babies OR toddler* or newborn* or neonate*)AND
(Feed*OReat
*ORhungerOR satietyOR satiationOR fullnessORmeal
*)
AND(cue* OR behavio?r or behavio?rs OR sign* OR communication)
Hunger and satiation in the first 2 years of life 207
© 2015 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd. Maternal & Child Nutrition (2016), 12, pp. 205–228
(single measures intraclass correlations by use of a one-way random effects model), r=0.82 (P< 0.001).
Overview of selected papers
Terminology
Several selected studies use the terms satiety andsatiation synonymously (e.g. Hodges et al. 2008;Llewellyn et al. 2012). This review distinguishesbetween these with ‘satiation’ referring to the processleading to the cessation of eating and ‘satiety’referring to the feeling of fullness after eating thatdetermines the interval before the next meal (Blundell& Bellisle, 2013).
Summary of selected studies
Themainmethodological features of the selected studiesare reported inTable 3.Most studieswere cross-sectional(n=11); others had longitudinal/repeated measures
components (n=8) or were experimental/quasi-experi-mental (n=6). Two studies were cohort studies. Theseinvolved questionnaires and one used modelling of her-itability of eating traits (Llewellyn et al. 2012). Most ofthe cross-sectional studies employed surveys and struc-tured observational methods. The exceptions to thiswere Hodges et al. (2008) and Anderson et al. (2001)who used semi-structured interviews and focus groups,respectively.
Areas of investigation
Six main research areas were identified in the retrievedstudies, as indicated below.A summary of findings fromthe selected papers appears in Table 3.1. Maternal perceptions of infants’ and toddlers’
hunger and satiation communications.2. Movement and sucking behaviours associated with
hunger and satiation.3. Impact of infant characteristics on the expression
and perception of hunger and satiation.4. Feeding behaviour norms in infancy.5. Feeding method, composition of milk, hunger, satia-
tion and satiety.6. Infant food preferences, how these are expressed and
implications for understanding hunger and satiation.
Findings
Maternal reports of feeding cues
Several studies have investigated mothers’ perceptionsof infants’ feeding cues. Anderson et al. (2001) usedfocus groups to examine maternal beliefs regardingreadiness for weaning. In this context, perceptions ofhunger related both to babies’ characteristics (e.g. ageand weight) and their behaviour (e.g. increased rateof milk consumption, agitation and changed sleepingpatterns). Mothers also reported being able to identifya ‘hungry cry’; however, this was differentiated fromother cries by time of day rather than the characteristicsof the cry itself. Reported satiation cues included thebaby seeming more ‘content’ and them wishing to eatless often.
Gross et al. (2010) also examined mothers’ percep-tions of infant hunger and satiation. In a survey relatingto general feeding rather than weaning, they found
Table 2. Inclusion and exclusion criteria
Inclusion criteria Exclusion criteria
– Qualitative or quantitative – Studies with a non-humanpopulation
– Peer reviewed – Studies with a primary focus onchildren over the age of 2 years
– Studies of feeding behavioursin typically developing childrenaged 0–2 years
– Studies with a primary focuson maternal (rather than infant)feeding behaviours
– Studies of hunger and satiationcues in typically developingchildren in the first 2 years of life
– Studies with a primary focuson feeding in premature infants
– Studies relating to infant ortoddler feeding in populationswith specific medical conditions(e.g. cystic fibrosis, developmentaldisorder, exposure to maternalsubstanceabuse and cleft lip)– Studies with a primary focus oninfant or toddler feeding inpopulations with maternaldisorder (e.g. depressive illnessand eating disorder)– Review articles/books– Papers not written in English– Papers where the full textversion is unavailable
208 J. McNally et al.
© 2015 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd. Maternal & Child Nutrition (2016), 12, pp. 205–228
Tab
le3.
Selected
papers
Autho
rsan
dtitle
Participan
tsan
dsample
Designan
dmetho
dsMainfind
ings
Implications
forun
derstand
ing
hung
eran
dsatia
tionin
infancy
Qua
lityratin
gsfirsta
ndsecond
raters
And
ersonet
al.(2001)
N=29
Cross-sectio
nal
Introd
uctio
nof
solid
swas
basedon
infant
age,size,w
eigh
tand
avarietyof
increased
infant
hung
ercues.
Bothinfant
beha
viou
rs(che
wingha
nds
andcrying
)an
dinfant
characteristics
(age
andsize)areused
bymothe
rsto
determ
inefeed
ingstatealon
gwith
external
cues
such
astim
e.
20/22
‘Rattling
theplate–
reason
san
dratio
nales
forearlyweaning
’
Multip
arou
san
dprim
iparou
smothe
rs,
meanage27
years,
ofba
bies
aged
betw
een
8an
d18
weeks,m
ean
age13
weeks.
Focus
grou
pdiscussion
sexploring
belie
fsan
dattitud
esregardingthe
introd
uctio
nof
solid
food
.Qua
litativeconten
tana
lysis.
19/22
Blossfieldet
al.(2007)
N=70
Qua
si-exp
erim
ental
Variabilityin
consum
ptionof
chop
pedcarrots
relatedto
familiarity
with
differen
ttextures,
high
erdietaryvariety,
food
fussinessan
dthenu
mbe
rof
teeth
infantspo
ssessed.
Amou
nteatenwas
associated
with
level
ofen
joym
ent.
Amou
ntof
food
consum
edvaries
accordingto
likingas
wella
swith
infant
characteristics(e.g.p
ickine
ssor
numbe
rof
teeth).
22/22
‘Texture
preferen
ces
of12-m
onth-old
infantsan
dtherole
ofearlyexpe
rien
ces’
39malean
d31
infants
aged
betw
een48
and
57weeks,m
eanage
52.7weeks.
Infantsfedchop
pedor
pureed
carrots.Measures–am
ount
offood
consum
ed,m
aterna
lratings
ofen
joym
enta
ndqu
estio
nnaire
measures,e.g.CEBQ*an
dFFQ.†
22/22
Darlin
gton
&Wrigh
t(2006)
N=75
Short-term
long
itudina
lSlow
weigh
tgainwas
sign
ificantly
associated
with
fearfultem
peramen
t.Fastw
eigh
tgainwas
associated
with
irritablebe
haviou
r.
Infant
tempe
ramen
tmay
affect
appe
tite
orthecommun
icationof
hung
er,
althou
ghmothe
rsmay
feed
irritable
babies
morein
orde
rto
soothe
them
.
20/22
‘The
influe
nceof
tempe
ramen
tonweigh
tgain
inearlyinfancy’
43malean
d32
female
infantsbe
tween8an
d12
weeks
ofage,mean
age10
weeks.
Infants’birthw
eigh
tsan
dweigh
tstake
nat
8–12
weeks.C
ompletion
ofIB
Q‡an
dBab
y’sDay
record
bymothe
rs.
20/22
Forestell&
Men
nella
(2012)
N=92
Exp
erim
ental
Infantswith
high
scores
onthe
approa
chdimen
sion
oftempe
ramen
tatemoreof
atest
vegetableforlong
eran
dwith
fewer
negativ
eexpression
s.
Infant
tempe
ramen
tmay
play
apa
rtin
food
acceptan
cean
dam
ount
consum
ed.
Con
sumptionisthereforeno
tpurely
determ
ined
byhu
nger.
22/22
‘Morethan
justapretty
face.
The
relatio
nshipbe
tween
infant’stempe
ramen
t,food
acceptan
ce,and
mothe
rs’pe
rcep
tions
oftheiren
joym
ento
ffoo
d’
48malean
d44
female
infants,mean
age52
weeks.
Infantsvide
o-recorded
whe
nfed
testvegetablein
labo
ratory
cond
ition
s.Measures:facial
expression
coding
;Infan
tTem
peramen
tScale
andmaterna
lratin
gsof
infants’en
joym
ent.
21/22
Gross
etal.(2010)
N=368
Cross-sectio
nal
Han
dsuckingwas
view
edas
ahu
nger
Com
mon
cues
areused
bymothe
rsto
iden
tifyhu
nger
andsatia
tion.
Low
er19/22
17/22
(Con
tinues)
Hunger and satiation in the first 2 years of life 209
© 2015 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd. Maternal & Child Nutrition (2016), 12, pp. 205–228
Tab
le3.
(Con
tinue
d)
Autho
rsan
dtitle
Participan
tsan
dsample
Designan
dmetho
dsMainfind
ings
Implications
forun
derstand
ing
hung
eran
dsatia
tionin
infancy
Qua
lityratin
gsfirsta
ndsecond
raters
cuean
dhe
adturningas
asatia
tion
cue.Mostm
othe
rs(72%
)be
lievedcrying
mustb
ean
indicatio
nof
hung
er.M
ost(93%)
also
believedtheirba
bies
couldsensetheirow
nsatie
ty.M
othe
rswith
high
BMIs
andlow
educationa
llevels
appe
ared
less
sensitive
tosatia
tioncues.
materna
ledu
catio
nallevel
andhigh
erBMImay
beassociated
with
lower
awaren
essof
infant
satia
tion.
‘Materna
lperceptions
ofinfant
hung
er,satiety,
andpressuring
feed
ing
styles
inan
urba
nLatina
WIC
popu
latio
n’
Mothe
rs,m
eanage
28yearswith
infants
aged
<20
weeks,m
ean
infant
age18.8weeks.
Second
aryan
alysisof
survey
data
regardingmaterna
lperceptions
ofhu
nger,satiatio
nan
dpressuring
feed
ingstyle.
Hod
geset
al.(2008)
N=71
Cross-sectio
nal
Mothe
rs’respon
sivene
ssto
feed
ingcues
was
variab
le.S
omefocused
onam
ount
consum
ed,
while
othe
rsfocused
oninfant
stateor
oral
beha
viou
rs.S
pecificity
ofcues
increasedwith
infant
age.
Arang
eof
overta
ndsubtle
hung
eran
dsatia
tioncues
arerepo
rted
bymothe
rs,
e.g.crying
,licking
thelip
s,spittingfood
outa
ndstop
ping
themeal.Differen
tmothe
rsfocusedon
differen
tcue
s.
19/22
‘Materna
ldecisions
abou
tthe
initiation
andterm
inationof
infant
feed
ing’
Mothe
rsof
fullterm
infantsat
12,26or
52weeks
ofage,
35males
and36
females.M
eanmaterna
lage,28.9years.
Structured
interviewingan
dqu
alita
tiveconten
tana
lysis.
17/22
Hod
geset
al.(2013)
N=144
Cross-sectio
nal
Mothe
rsrespon
dedmore
tohu
nger
than
fulln
ess
cues.R
espo
nsiven
essto
cues
was
associated
with
materna
lcha
racteristics
(edu
catio
n,BMIan
dbreastfeed
ingdu
ratio
n).
Mothe
rsweremore
respon
sive
tohu
nger
cues
inolde
rself-feed
ing
child
ren.
Hun
gercues
may
bemoresalient
for
mothe
rsthan
satia
tioncues.M
othe
rsap
pear
morerespon
sive
tothecues
ofolde
rchild
ren.
Respo
nsiven
essto
satia
tionap
pearsto
beassociated
with
high
ered
ucationa
llevel,low
erBMI
andlong
erbreastfeed
ingdu
ratio
n.
22/22
‘Develop
men
tofthe
respon
sivene
ssto
child
feed
ingcues
scale’
Mothe
rsof
28to
104-
week-oldinfantsan
dtodd
lers,m
eanmaterna
lan
dinfant
agean
dM
:Fratio
unkn
own.
Develop
men
tand
testingof
anob
servationa
lmeasure
ofcaregiverrespon
sivene
ssto
child
feed
ingcues
usingstructured
observationof
infant/to
ddler
feed
ing.
21/22
Hwan
g(1978)
N=58
Short-term
long
itudina
lOnda
yfour,m
ean
numbe
rof
feed
ing
New
born
malean
dfemaleinfants
appe
arto
show
differen
tfeeding
14/22
15/22
(Con
tinues)
210 J. McNally et al.
© 2015 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd. Maternal & Child Nutrition (2016), 12, pp. 205–228
Tab
le3.
(Con
tinue
d)
Autho
rsan
dtitle
Participan
tsan
dsample
Designan
dmetho
dsMainfind
ings
Implications
forun
derstand
ing
hung
eran
dsatia
tionin
infancy
Qua
lityratin
gsfirsta
ndsecond
raters
period
swas
sign
ificantly
high
erformalethan
femaleinfants.The
first
feed
ingpe
riod
onda
yfour
was
sign
ificantly
long
erforfemales
than
males.D
uringfeed
ing
onbo
thda
ys,m
ale
infantscriedmore
than
females.
beha
viou
rs,w
ithpo
ssible
implications
formaterna
lperceptions
ofhu
nger
andsatia
tion.
‘Mothe
r–infant
interaction–effects
ofsexon
infant
feed
ingbe
havior’
Prim
iparou
smothe
rs23
malean
d35
female
newbo
rninfantsob
served
at<1week(2
and4da
ys).
Materna
lage
unkn
own.
Tim
esampled
observationof
two
sing
lebreastfeed
ingsessions
onda
ystw
oan
dfour
oflifein
hospita
lsettin
g.
Lew
&Butterw
orth
(1995)
N=18
Cross-sectio
nal
Nodifferen
cefoun
dbe
tweenthedistribu
tion
ofha
nd–facean
dha
nd–
mou
thcontactspre-feed
.Propo
rtionof
hand
–mou
thcontactswas
notg
reater
before
feed
ingthan
after
feed
ing.Ope
nmou
thpo
stures
before
hand
–
mou
thcontactson
lyoccurred
before
feed
ing.
Ope
nmou
thpo
stures
priorto
hand
mou
thcontactsmay
bean
indicatio
nof
hung
erin
newbo
rninfants.
21/22
‘The
effectsof
hung
eron
hand
–mou
thcoordina
tion
inne
wbo
rninfants’
New
born
term
infants
born
betw
een38
and
42weeks
gestationa
lageob
served
at1
weekor
youn
ger.
Structured
observations
ofinfants
before
andaftermilk
feed
ingby
form
ulaor
breast.A
nalysisof
differen
cesbe
tweenha
nd–face
andha
nd–m
outh
contacts.
20/22
Llewellynet
al.(2011)
N=2402
Coh
ortstudy
Four
appe
titeconstructs
wereiden
tified
–food
respon
sivene
ss,enjoy
men
tof
food
,satiety
respon
sivene
ssan
dslow
ness
ineatin
g.Allconstructs
hadgo
odinternal
relia
bilityan
dcorrelated
with
‘gen
eral’ap
petite.
Group
differen
ceswere
observed
inrelatio
nto
appe
titivebe
haviou
rs.
Differen
tgroup
sof
infantsha
vedifferen
tapp
etitive
beha
viou
rs;e.g.,
males
appe
arto
have
larger
appe
tites
andto
beless
satie
tyrespon
sive
than
females;p
rematureinfantsha
vesm
aller
appe
tites
andhigh
ersatie
tysensitivity
than
term
infants;an
dbreastfedinfants
appe
arless
satie
tyrespon
sive
than
form
ula-fedinfants.
21/22
‘Develop
men
tand
factor
structureof
theBab
yEating
Beh
aviour
Que
stionn
aire
intheGem
inib
irth
coho
rt’
1194
malean
d1208
femaleinfants,mean
age32.8weeks,ran
ge16–80weeks.
BEBQ
§formilk
-fed
infants.
Que
stionn
aire
itemsrefine
dvia
interviewswith
asampleof
mothe
rs(n
=10).
21/22
Llewellynet
al.(2012)
N=4634
Coh
ortstudy
Infant
weigh
twas
correlated
with
21/22
21/22
(Con
tinues)
Hunger and satiation in the first 2 years of life 211
© 2015 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd. Maternal & Child Nutrition (2016), 12, pp. 205–228
Tab
le3.
(Con
tinue
d)
Autho
rsan
dtitle
Participan
tsan
dsample
Designan
dmetho
dsMainfind
ings
Implications
forun
derstand
ing
hung
eran
dsatia
tionin
infancy
Qua
lityratin
gsfirsta
ndsecond
raters
BEBQ
appe
titetraits.
Gen
eticinflue
ncewas
show
nforsatie
tyrespon
sivene
ss,slowne
ssin
eatin
gan
dap
petite.
Eatingtraitsof
infantsarehe
ritable.
Exp
ressionof
appe
titeistherefore
influe
nced
bygeno
type
.
‘Inh
erite
dbe
havioral
suscep
tibility
toad
iposity
ininfancy:amultiv
ariate
gene
tican
alysisof
appe
tite
andweigh
tintheGem
ini
birthcoho
rt’
2289
males
and2345
femaleinfants,
meanage32.8weeks,
rang
e16–80weeks.
BEBQ
§an
dinfant
weigh
tmeasurestake
nat
12weeks
+multiv
ariate
gene
ticmod
ellin
g.
McM
eekinet
al.(2013)
N=698
Cross-sectio
nal
Mothe
rsof
infants
with
difficult
tempe
ramen
tsrepo
rted
alower
awaren
essof
hung
eran
dsatia
tioncues
andweremorelik
ely
tousefood
tosoothe
.
Itmay
bedifficultformothe
rsof
infantswith
difficulttempe
ramen
tsto
distingu
ishhu
nger
andsatia
tioncues
from
othe
rkind
sof
distress.M
aterna
lde
pression
also
appe
arsto
beassociated
with
lower
awaren
essof
infant
feed
ingcues
andgreateruseof
food
tocalm
babies.
21/22
‘Associatio
nsbe
tweeninfant
tempe
ramen
tand
early
feed
ingpractices.A
cross-
sectiona
lstudy
ofAustralian
mothe
r–infant
dyad
sfrom
theno
urishrand
omised
controlle
dtrial’
342malean
d356
femaleinfantsbe
tween
8an
d28
weeks
ofprim
iparou
smothe
rs.
Meaninfant
age17.2
weeks.M
eanmaterna
lage30.1years.
Materna
lself-repo
rton
STSI
¶
andIFQ.∥
20/22
Men
nella
etal.(2001)
N=46
Exp
erim
ental
Infantsexpo
sedto
carrot
flavou
rsin
uteroor
during
lactationexhibited
fewer
negativ
efacial
expression
sto
carrot-
flavou
redcereal
than
plaincereal.Infan
tsexpo
sedto
carrot
flavou
rin
uterowere
perceivedby
mothe
rsto
enjoycarrot-
flavou
redcereal
morethan
plaincereal.
Previou
sexpo
sure
toflavou
rlead
sto
greateracceptan
ce,g
reater
enjoym
ent
andgreaterconsum
ption.
Amou
nteatenisno
tpurelyde
term
ined
byhu
nger.F
aciale
xpressionmay
beon
eway
ofdifferen
tiatin
gbe
tweencessation
ofeatin
gdu
eto
dislikean
dthat
arising
from
satia
tion.
21/22
‘Prena
tala
ndpo
stna
talfl
avor
learning
byhu
man
infants’
28malean
d18
female
infants.Meaninfant
age22.6weeks.
Infantsassign
edto
oneof
threegrou
psinvo
lving
drinking
carrot
juiceor
water
during
pregna
ncyan
dbreastfeed
ing.Respo
nses
tocerealscontaining
water
orcarrot
juiceweremeasuredvia
facial
expression
coding
,materna
lratings
ofen
joym
ent
andam
ount
consum
ed.
20/22
Men
nella
etal.(2009)
N=97
Exp
erim
ental
Typ
eof
form
ulafed
toinfantsim
pacted
onrespon
sesto
differen
ttastin
gcereals.Formula-fed
infantseatin
gcomplem
entary
food
s
Prior
expo
sure
lead
sto
greater
consum
ptionof
food
with
familiar
taste
compo
unds.N
egativefacial
expression
may
prov
ideaba
sisfordistingu
ishing
betw
eensatia
tionan
ddislike.
21/22
‘Early
milk
feed
inginflue
nces
tasteacceptan
cean
dlik
ing
during
infancy’
Fullterm
infantsbe
tween
16an
d36
weeks,m
ean
age25
weeks,w
hoha
dbe
enspoo
nfedba
bycereal
forat
least2
weeks.
Subg
roup
sof
breastfedan
dtw
otype
sof
form
ula-fed
babies
wereob
served
ondifferen
toccasions
tomeasure
acceptan
ceof
sweet,salty,b
itter,
savo
ury,sour
andplaincereals.
21/22
(Con
tinues)
212 J. McNally et al.
© 2015 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd. Maternal & Child Nutrition (2016), 12, pp. 205–228
Tab
le3.
(Con
tinue
d)
Autho
rsan
dtitle
Participan
tsan
dsample
Designan
dmetho
dsMainfind
ings
Implications
forun
derstand
ing
hung
eran
dsatia
tionin
infancy
Qua
lityratin
gsfirsta
ndsecond
raters
show
edpreferen
cesfor
thetastes
offood
sto
which
they
had
alread
ybe
enexpo
sed.
Nisbe
tt&
Gurwitz
(1970)
(Exp
erim
ent1
)Exp
erim
ental
Heavy
infantswere
morerespon
sive
than
med
ium
andlight
weigh
tinfan
tsto
sweetene
dform
ula.
Fem
aleinfants
respon
dedmoreto
sweetene
dform
ula
than
males.H
eavier
andfemaleinfants
consum
edsign
ificantly
less
inthesm
allh
ole
cond
ition
.Med
ium
weigh
t,lig
hter
weigh
tan
dmaleinfants’
consum
ptionwas
not
sign
ificantly
affected
bythiscond
ition
.
Sexan
dweigh
tmay
impa
cton
satie
tyrespon
sivene
ssto
sweetene
dmilk
.Se
xan
dweigh
tmay
impa
cton
effort
expe
nded
infeed
ingan
dconseq
uent
amou
ntconsum
ed.
18/22
‘Weigh
t,sex,an
dtheeatin
gbe
havior
ofhu
man
newbo
rns’
N=42
Infantsin
threeweigh
tgroup
swerealternatelyfedasw
eet
andstan
dard
form
ulaof
the
sameen
ergy
density
daily
atthesametim
e.Intake
perfeed
was
recorded
.Infan
tswere
form
ulafedov
er2da
yswith
ano
rmal
orsm
allh
oleteat.
Mothe
rsrecorded
consum
ption
andtim
eat
which
feed
sbe
gan
anden
ded.
17/22
22malean
d20
femalene
wbo
rninfants.
(Exp
erim
ent2
)N=34
18malean
d16
female
newbo
rninfants.
Parkinson
&Drewett(2001)
N=100
Cross-sectio
nal
Despite
similarity
intheageof
the
todd
lers
self-feed
ing
andbe
ingfedvaried
high
ly.Intak
ewas
correlated
with
numbe
rof
bitesrather
than
meald
uration.
Self-feed
ing
ledto
along
ermealtim
eon
average,while
long
ermealswereassociated
with
lower
food
intake
.
Num
berof
bitesmay
beabe
tter
indicatio
nof
hung
erlevelsthan
meal
duratio
n,althou
ghaccoun
tneeds
tobe
take
nof
whe
ther
thechild
selffeed
sor
isfedby
themothe
r.Se
lf-feed
ingtend
sto
lead
tolong
ermeald
urationan
dlower
intake
intodd
lers.
20/22
‘Feeding
beha
viou
rin
the
weaning
period
’
Mothe
rinfant
dyad
s.51
malean
d49
female.Infants/todd
lers
observed
betw
een52
and61
weeks,m
eanage
55weeks.M
aterna
lage
rang
e≤2
4to
≥35years.
Naturalistic
observationof
two
mealtim
esan
alysed
usingall
occurren
cesampling.Cod
esde
velope
dregardingmothe
rs’
feed
ingof
child
renan
dchild
self-feed
ingan
drelatedchild
beha
viou
rs.
17/22
(Con
tinues)
Hunger and satiation in the first 2 years of life 213
© 2015 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd. Maternal & Child Nutrition (2016), 12, pp. 205–228
Tab
le3.
(Con
tinue
d)
Autho
rsan
dtitle
Participan
tsan
dsample
Designan
dmetho
dsMainfind
ings
Implications
forun
derstand
ing
hung
eran
dsatia
tionin
infancy
Qua
lityratin
gsfirsta
ndsecond
raters
Pau
leta
l.(1996)
N=20
Short-term
long
itudina
lTwo-week-oldinfants
werevisually
attentive
whe
nfeed
ing.Motor
activ
ityan
dalertness
shifted
from
pre-feed
ing
topo
st-feeding
time
during
thefirst6
mon
ths.
Motor
beha
viou
rsdiffer
with
feed
ing
statean
dat
differen
tpointsin
the
feed
ingcycleaccordingto
infant
age.
Differen
cesalso
appe
arto
existinthe
suckingbe
haviou
rsan
dconsum
ption
patterns
ofform
ula-fedan
dmilk
-fed
babies.
15/22
‘Infan
tfeeding
beha
vior:
developm
entinpa
tterns
andmotivation’
Fullterm
infantsat
2,10,18an
d26
weeks.
Sexun
know
n.
Structured
observationpriorto
during
andaftermilk
feed
ing.
Observatio
nssupp
ortedby
vide
oan
dpo
lygrap
hicrecording
ofbe
haviou
rssuch
assucking,
breathingan
dsw
allowing.
13/22
Reauet
al.(1996)
N=281
Cross-sectio
nal
Nodifferen
ceswere
repo
rted
betw
eenfeed
ing
timein
term
sof
birth
weigh
torbirthorde
r.90%
ofinfantsan
dtodd
lers
took
fewer
than
30min
toeata
meal.Rep
ortsof
feed
ing
prob
lemswereespe
cially
common
intodd
lers.
Feeding
prob
lemsarecommon
ininfantsan
despe
cially
todd
lers.
Variabilityin
hung
erisno
rmal.
Meald
urations
beyo
nd30
min
may
indicate
feed
ingprob
lems.
17/22
‘Infan
tand
todd
lerfeed
ing
patterns
andprob
lems:
norm
ativeda
taan
da
newdirection’
157malean
d124female
infantsan
dtodd
lers,
agerang
e12–108
weeks.
Meanageun
know
n.
Survey
research
usingan
unvalid
ated
self-repo
rtqu
estio
nnaire.Q
uestionn
aire
itemsinclud
edinfant
and
todd
lerhu
nger
atthestarto
fameal,feed
ingbe
haviou
rs,
feed
ingprob
lemsan
dfeed
ing
duratio
n.
14/22
Skinne
ret
al.(1998)
N=98
Lon
gitudina
lHun
gercommun
ication
appe
ared
before
satia
tion
(4.4–5.7an
d5.8–7.5mon
ths,
respectiv
ely).E
xtreme
variab
ility
was
iden
tified
incommun
icative
beha
viou
rsat
mealtim
es.F
oodlik
esan
ddislikes
increased
with
ageas
didverbal
commun
icationrelatin
gto
eatin
g.
Hun
geran
dsatia
tioncommun
ication
ishigh
lyvariab
le.L
ikes/dislik
esare
easier
todiscernin
olde
rinfants
than
youn
geron
es,alth
ough
liking
was
exhibitedless
than
dislike
throug
hfacial
expression
.
19/22
‘Mealtimecommun
ication
patterns
ofinfantsfrom
2to
24mon
thsof
age’
Infant
mothe
rdy
ads.
Typ
ically
developing
infantsfrom
8to
96weeks.Infan
tsex,
meaninfant
agean
dmean
materna
lage
unkn
own.
Structured
interviewsan
dresearcher
administered
questio
nnaire
at10
timepo
ints
from
2to
24mon
ths.
Participan
tswererand
omly
assign
edto
sixinterviews.Data
werecollected
regardinginfant
andtodd
lermealtime
commun
icationat
each
timepo
int.
15/22
Steven
sonet
al.(1990)
N=34
Cross-sectio
nal
Feeding
outcom
eswere
similarforbo
thgrou
ps.
Pre-term
infantsfussed
moredu
ring
feed
ingthan
term
infants.Vocalisations
didno
tdiffer
betw
een
Exp
ressionof
hung
ermay
differ
subtly
inprem
atureba
bies.M
othe
rsof
theseba
bies
offerfood
morein
respon
seto
vocalisationthan
those
offullterm
babies.
17/22
‘Rhy
thmsin
thedialog
ueof
infant
feed
ing:preterm
andterm
infants’
Mothe
rinfant
dyad
swith
17pre-term
infantsan
d17
full
term
infantsat
32weeks
(age
gestationa
lly
Solid
food
feed
inginteractions
vide
o-recorded
throug
haon
e-way
mirror.Cod
ingof
materna
lan
dinfant
beha
viou
rssuch
asgaze,v
ocalisationan
dself-feed
.
15/22
(Con
tinues)
214 J. McNally et al.
© 2015 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd. Maternal & Child Nutrition (2016), 12, pp. 205–228
Tab
le3.
(Con
tinue
d)
Autho
rsan
dtitle
Participan
tsan
dsample
Designan
dmetho
dsMainfind
ings
Implications
forun
derstand
ing
hung
eran
dsatia
tionin
infancy
Qua
lityratin
gsfirsta
ndsecond
raters
grou
ps.H
owever,m
othe
rsof
prem
atureba
bies
respon
dedto
vocalisations
with
offers
offood
morethan
mothe
rsof
term
infants.
adjusted
).Materna
lage
andinfant
sexun
know
n.
Turke
witz
etal.(1966)
N=35
Cross-sectio
nal
The
prop
ortio
nof
hand
flexionto
extension
mov
emen
tswas
greater
priorto
feed
ingthan
post-feeding
,regardless
ofwhe
ther
infantswere
awak
eor
asleep
.
Han
dflexionap
pearsto
beassociated
with
hung
erin
newbo
rninfants.
17/22
‘Relationshipbe
tweenfeed
ing
cond
ition
andorganizatio
nof
flexor–exten
sormov
emen
tsin
thehu
man
neon
ate’
New
born
femaleinfants,
aged
<1to
1.5weeks,
meanage≏1week
Observatio
nalstudy
offlexion
andextensionmov
emen
tsof
infants’ha
ndsdu
ring
two5-min
period
spriorto
andpo
st-feeding
.
19/22
vanDijk
etal.(2009)
N=20
Short-term
long
itudina
lAmou
ntconsum
edpe
rmealincreased
over
time.
Mealtimedu
ratio
nwas
stab
leacross
time
(average
8to
10min).
Freq
uencyof
food
refusalsde
creased
over
time.Variability
was
foun
din
feed
ing
beha
viou
rsbo
thacross
andwith
ininfants
particularly
during
the
period
afterthe
introd
uctio
nof
solid
s.
Infant
feed
ingbe
haviou
rishigh
lyvariab
ledu
ring
theweaning
period
;ho
wever,m
eald
urationincreases
over
time.Foo
drefusalisalso
common
during
weaning
.
19/22
‘Variabilityin
eatin
gbe
havior
throug
hout
the
weaning
period
’
12malean
d8female
fullterm
infants
aged
betw
een16
and24
weeks,
meanage22
weeks.
Naturalistic
observationof
infantsan
dcaregivers
across
a12-w
eekpe
riod
follo
wingthe
introd
uctio
nof
solid
s.Feeding
vide
o-recorded
andcode
d.
17/22
Ven
tura
etal.(2012)
N=30
Exp
erim
ental
Infantsconsum
edsign
ificantly
less
cows’
milk
form
ulaan
dshow
edhigh
ersatie
tyratio
saftertheen
hanced
cows’milk
form
ulaan
dtheproteinhy
drolysate
Formulacompo
sitio
nim
pactson
both
satia
tionan
dsatie
tyregardless
ofen
ergy
conten
t.The
stud
ypo
tentially
offers
five
means
ofiden
tifying
hung
eran
dsatie
tyin
aresearch
context:am
ount
ofmilk
initially
consum
ed,rateof
consum
ption,
respon
seto
additio
nalo
ffersof
milk
,
21/22
‘Infan
tregulationof
intake
:theeffect
offree
glutam
ate
conten
tininfant
form
ulas’
14malean
d16
female
infants,mean
age8.5weeks.
Infantswerefedon
eof
three
differen
tformulas
over
3da
ys:
cows’milk
form
ula,aprotein
hydrolysateform
ulaan
dcows’
milk
form
ulawith
adde
dfree
glutam
ate.Sa
tiety
ratio
swere
calculated
foreach
form
ula.
20/22
(Con
tinues)
Hunger and satiation in the first 2 years of life 215
© 2015 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd. Maternal & Child Nutrition (2016), 12, pp. 205–228
Tab
le3.
(Con
tinue
d)
Autho
rsan
dtitle
Participan
tsan
dsample
Designan
dmetho
dsMainfind
ings
Implications
forun
derstand
ing
hung
eran
dsatia
tionin
infancy
Qua
lityratin
gsfirsta
ndsecond
raters
than
stan
dard
cows’
milk
form
ula.
compe
nsationfeed
ingat
subseq
uent
meala
ndsatie
tyratio
.Wasseret
al.(2011)
N=217
Cross-sectio
nal
Infantswith
high
distress
tolim
itatio
nsweremore
likelyto
receivesolid
food
searly.Materna
lob
esity
was
associated
with
earlyintrod
uctio
nof
solid
s,an
dmaterna
lde
pression
was
associated
with
theearly
introd
uctio
nof
juice.
Infantswith
difficulttempe
ramen
tsmay
bepe
rceivedto
behu
ngrier
ormay
befedto
soothe
them
.Infan
tswith
difficulttempe
ramen
tsmay
also
begivenjuiceto
soothe
them
oras
acoping
respon
seby
depressedmothe
rs.
Obe
semothe
rsmay
misinterpret
difficulttempe
ramen
tfor
hung
eror
may
have
larger,h
ungrierba
bies.
22/22
‘Infan
tspe
rceivedas
“fussy”aremorelik
ely
toreceivecomplem
entary
food
sbe
fore
4mon
ths’
Infant
mothe
rdy
ads
visitedat
12,24,
36,48an
d72
weeks
ofinfant
age.101males
and116females.M
ean
materna
lage
22.7years.
Infant
feed
ingpa
tterns
assessed
thorou
ghdietaryhistoryan
d24-h
dietaryrecall.
Infant
tempe
ramen
ttraits
measuredby
Infant
Beh
aviour
Que
stionn
aire
–revised
22/22
Wrigh
teta
l.(1980)
N=190
Short-term
long
itudina
lWhe
relong
intervals
occurred
betw
een
feed
s,breastfedinfants
consum
edalarger
meal
than
form
ula-fedinfants.
Differen
ceswereno
ted
inthesuckingpa
ttern
ofbreastfedan
dform
ula-fedinfants.
Overthefirst2
mon
ths,
diurna
ldifferen
ces
appe
ared
inthesize
offeed
consum
edin
breastfedbu
tnot
form
ula-fedinfants.
Breastfed
andform
ula-fedba
bies
show
differen
tpatternsof
feed
ing
beha
viou
rin
term
sof
sucking
beha
viou
ran
dvariab
ility
ofconsum
ption.
15/22
‘Dobreast-feeding
mothe
rskn
owho
whu
ngry
theirba
bies
are?’
132form
ula-fedan
d58
breastfedinfantsin
thefirst8
weeks
oflife.
Infant
sexun
know
n.
Video
recordingof
feed
ing
sessions
atmon
thly
intervalsfrom
justafterbirthforform
ulaan
dbreastfedinfants.Mothe
rsalso
kept
diariesof
infants’feed
s.
15/22
Wrigh
t(1986)
N=30
Short-term
long
itudina
l77%
ofmothe
rsrepo
rted
theirinfants’
hung
ervaried
across
theda
y,moreso
forbo
ysthan
girls.
Milk
intake
didno
tvary
sign
ificantly
across
theda
y,an
dno
Mostb
reastfeeding
mothe
rswereab
leto
assess
accurately
theirinfant’shu
nger.H
owever,
infant
sexmay
exerta
ninflue
nceon
mothe
rs’
interpretatio
nof
hung
ercues.M
othe
rsof
boys
may
misinterpreth
ighactiv
ityan
darou
sallevels
ashu
nger.
15/22
‘The
developm
ento
fdifferen
cesin
thefeed
ing
beha
viou
rof
form
ulaan
dbreastfedhu
man
infants
from
birthto
2mon
ths’
Mothe
rsof
14male
and16
female
breastfedinfants,
meaninfant
age4
weeks.M
eanmaterna
lageun
know
n.
Mothe
rsaske
dthreequ
estio
nsregardinginfant
hung
er.14
mothe
rsalso
kept
a4-da
ydiary
offeed
s,prov
ided
hung
erratin
gsan
dweigh
edinfants
before
andafterfeed
s.
16/22
(Con
tinues)
216 J. McNally et al.
© 2015 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd. Maternal & Child Nutrition (2016), 12, pp. 205–228
Tab
le3.
(Con
tinue
d)
Autho
rsan
dtitle
Participan
tsan
dsample
Designan
dmetho
dsMainfind
ings
Implications
forun
derstand
ing
hung
eran
dsatia
tionin
infancy
Qua
lityratin
gsfirsta
ndsecond
raters
sign
ificant
differen
cewas
repo
rted
betw
een
boys’an
dgirls’milk
consum
ption.
Mothe
rs’
ratin
gsof
hung
ercorrelated
with
those
forintake
for9of
the14
mothe
rs.
You
ng&
Drewett(2000)
N=30
Short-term
long
itudina
lMed
ianmeald
uration
was
17min.T
here
was
high
variab
ility
betw
eeninfants
infeed
ingbe
haviou
rsan
dacross
meals.
Refusal
was
acommon
buth
ighly
variab
lebe
haviou
r–
med
ian11,ran
ge0–101.
At5
2weeks
ofage,todd
lers’eatingbe
haviou
ris
variab
leacross
meals.F
oodrefusaliscommon
inthisagegrou
p.Tod
dlersalso
consum
ede
sserts
faster
andwith
fewer
refusalsthan
maincourses.
19/22
‘Eatingbe
haviou
ran
dits
variab
ility
in1-year-old
child
ren’
13femalean
d17
male
infantsaged
50–57weeks
old.
Meanageun
know
n.
Video
-recorde
dob
servations
ofmealsin
theho
meov
er2
consecutiveda
yscode
dwith
asche
mede
velope
dfrom
two
othe
rstud
ies.
18/22
*Child
EatingBeh
aviour
Que
stionn
aire.
†Foo
dFrequ
ency
Que
stionn
aire.
‡Infant
Beh
aviour
Que
stionn
aire.
§ Bab
yEatingBeh
aviour
Que
stionn
aire.
¶Sh
ortT
empe
ramen
tScale
forInfants.
∥ Infan
tFeeding
Que
stionn
aire.
Hunger and satiation in the first 2 years of life 217
© 2015 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd. Maternal & Child Nutrition (2016), 12, pp. 205–228
mothers were attentive to four hunger and satiationbehaviours: hand sucking, head turning, crying andbabies ‘knowing’ they were full. The list of cues wasgenerated by the authors, although participants agreedthey used them to identify hunger and satiation. Grosset al. (2010) also found associations between certainmaternal characteristics and perceptions of feedingcues: obese mothers were less likely to agree thatbabies could sense their own satiation, and maternalobesity and longer breastfeeding history were associ-ated with perceiving hand sucking as indicating hunger.
In a study involving semi-structured interviews,Hodges et al. (2008) investigated cues that promptedmothers to initiate and end feeding. Like Andersonet al. (2001), the authors foundmothers used both infantbehaviours and external cues (e.g. time) to identify hun-ger. Commonly identified hunger cues in this studywerecrying, fussing and licking the lips, and these werereported across several age groups (3, 6 and 12months).Commonly reported satiation cues included pullingaway, spitting food out and stopping feeding. Theauthors also found that the prominence, intensity andspecificity of infant cues guided decisions about initiat-ing and ending feeds and that mothers found cues easierto interpret with increasing infant age.
In a later study, Hodges et al. (2013) described thedevelopment of the Responsiveness to Child FeedingCues Scale (RCFCS). In devising this, the authors iden-tified 20 types of hunger cue and 28 types of satiationcue. Hunger and satiation cues were further categorisedas ‘early’ (e.g. increased alertness), ‘active’ (e.g. excit-atory movements) and ‘late’ (e.g. fussing and crying)in order to reflect changes in cue intensity. Satiationcues were not described directly in the study, althoughthe authors found mothers’ responsiveness to satiationto be predicted by certain maternal characteristics(lower BMI, longer breastfeeding duration and highereducational level). They also found mothers to be moreresponsive to hunger than satiation cues.
The only longitudinal study retrieved in the searchwas conducted by Skinner et al. (1998). They examinedmealtime communication behaviours in infants andtoddlers using structured interviews with mothers.The authors found that hunger behaviours, e.g. open-ing the mouth for the spoon, appeared at a youngerage than satiation behaviours, e.g. closing the mouth
to reject food (4.4 to 5.7months vs. 5.8 to 7.5months,respectively). They also noted that overall hunger andsatiation behaviours were highly variable acrossinfants. The study also examined infants’ communica-tion of food likes and dislikes. Findings relating to thisare discussed alongside research relating to foodpreferences.
Wright (1986) also observed variability in the expres-sion of hunger by infants although this time by infantsex.Mothers of breastfed babies were asked when theirinfants were most hungry, how they identified hungerand also about the variability of their breastmilk supply.All mothers ofmale babies agreed hunger varied acrossthe day, but only around half the mothers of femalesreported this. Mothers identified increased frequencyof feeding as a hunger cue for males, whereas agitationwas cited for females. Late afternoon and early eveningwere identified as hungry times for males, whilemothers of females associated hungry times with feelingthey had less breast milk, rather than time of day.Despite such differences, recordings of infant weighttaken from before and after feeding indicated that rela-tively constant volumes of milk were consumed by girlsand boys across the day. It appears then that mothers ofmale and female infants may interpret different behav-iours as hunger depending on the sex of their child(Wright 1986).
Movement and sucking behaviours associated with hunger andsatiation
A few studies have involved observations of infantsunder controlled conditions before, during and afterfeeding. Lew & Butterworth (1995) observed hand tomouth contacts in newborns pre-prandially and post-prandially. They found that hunger did not affect wherehand contacts were made on the face, and there was nodifference between the proportion of hand–mouth con-tacts before and after feeding. However, hand–mouthcontacts preceded by open mouth postures were onlyobserved before feeding. This coordination of openmouth postures with hand–mouth contacts may there-fore be associated with hunger in newborns.
Similarly, Turkewitz et al. (1966) examined handmovements before and after feeding. The researchersobserved the flexion and extension movements of
218 J. McNally et al.
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newborns’ hands and found that regardless of whetherinfants were awake or asleep, the proportion of flexionmovements was significantly greater before feedingthan after. Flexed hand postures may therefore beanother behavioural indication of hunger in younginfants.
While Turkewitz et al. (1966) and Lew andButterworth (1995) investigated infant hand move-ments before and after feeding, Paul et al. (1996)examined several aspects of pre-prandial and post-prandial behaviour. They video-recorded milk feedsin infants at 8-week intervals in infants between 2 and26weeks of age. The researchers found sucking behav-iours increased in rate with infant age, while thenumber and length of pauses in sucking decreased.Breast and formula feeding behaviours were comparedat 2weeks of age but not beyond this; breastfed infantsconsumed milk at less than a third of the rate offormula-fed babies, and breast feeds took around fourtimes longer than formula feeds. The authors alsoexamined motor activity during feeding. This was lowfor all age groups (Paul et al., 1996). Following feeding,motor activity andmuscle tone decreased in 2-week-oldinfants. However, post-feedingmotor activity increasedin older infants. The study therefore indicates thatinfant sucking and motor activity vary with hungerand satiation, although the precise pattern of behaviourdiffers with infant age and feeding method.
Effect of infant characteristics on hunger, satiation and feedingbehaviour
Several studies have examined associations betweeninfant characteristics and feeding behaviour. Using theInfant Temperament Scale (Carey & McDevitt, 1978),Forestell andMennella (2012) investigated associationsbetween temperament and liking of a novel vegetable.They found that infants with higher ratings on‘approach’ traits (those more willing to approach novelsituations) ate more green beans, and for longer, andshowed fewer negative facial expressions (assessed bymothers) than those with lower approach ratings.
Darlington & Wright (2006) also investigated theimpact of temperament on feeding although in relationto weight gain in the first 2months of life. Using theInfant Behaviour Questionnaire (IBQ) (Rothbart,
1981), they found that infants with high fearfulnessscores exhibited slowweight gain, while those with highscores on ‘distress to limitations’ showed faster weightgain. The IBQ was also used to investigate infant tem-perament and the early introduction of complementaryfeeds by low-income mothers by Wasser et al. (2011).They noted that both ‘distress to limitations’ and infant‘activity level’ were significantly associated with theintroduction of solids before 4months of age. In addi-tion, Wasser et al. found maternal obesity to be signifi-cantly associated with the early introduction of solids,suggesting again that maternal characteristics mayinfluence perceptions of infant hunger.
Research by McMeekin et al. (2013) further sup-ports the contention that both infant and maternalcharacteristics influence perceptions of feeding cues.In a study using the Short Temperament Scale(STSI) (Sanson et al. 1987), they found thatmothers of babies with ‘difficult temperaments’ weresignificantly more likely to feed their babies to calmthem. Meanwhile, regarding maternal characteristics,mothers with higher scores on the Edinburgh PostNatal Depression Scale (Cox et al. 1987) werefound to be significantly less aware of infant feedingcues and more likely to feed their babies to calmthem.
Llewellyn et al. (2011) also explored the impactof infant characteristics on feeding behaviour. Indeveloping the Baby Eating Questionnaire (BEBQ),they examined associations between individual char-acteristics and feeding traits. Male babies werefound to have larger appetites, to respond more tofood cues and to be less satiety responsive (sensitiveto feeling full and fullness between meals) thanfemales. Premature infants were reported to havesmaller appetites, lower enjoyment of food, slowerfeeding and higher satiety responsiveness than fullterm infants. Breastfed babies had larger overallappetites, were more responsive to food cues andwere less sensitive to satiety cues than mixed-fedor formula-fed babies. Finally, infants with higherbirthweights had larger appetites, fed more quickly,enjoyed food more and were less responsive to sati-ety than lower birthweight babies. Thus, sex,birthweight and gestational age at birth may allinfluence infant appetite and feeding cues.
Hunger and satiation in the first 2 years of life 219
© 2015 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd. Maternal & Child Nutrition (2016), 12, pp. 205–228
The BEBQ was also used by Llewellyn et al.(2012) to investigate relationships between genotypeand eating traits. In this large scale twin study,details of zygosity, infant age, gestational age andsex were collected alongside appetite data at theage of 3months. Significant shared genetic effectswere found in twins regarding weight, slowness ineating traits, satiety responsiveness and appetitesize. The findings therefore suggest that appetiteand behaviours associated with this are shaped inpart by individual genetic make-up.
Additional evidence that gestational age at birthinfluences feeding behaviour comes from researchby Stevenson et al. (1990). They observed feedingbehaviour in term and pre-term infants. No signifi-cant differences were found between groups regard-ing amount eaten, infant vocalisations or infants’gaze at mothers during feeding. However, pre-terminfants were significantly fussier during feeding thanterm infants, and mothers of pre-term infantsresponded to vocalisations with offers of food, whilemothers of term infants did not.
In relation to sex and feeding cues, an observa-tional study of newborns by Hwang (1978) foundthat on the fourth day of life, boys suckled signifi-cantly more frequently and for shorter periods thangirls. In addition, Hwang noted that, during feeding,males were significantly more likely to fuss thanfemales, both on the second and fourth days afterbirth. Nisbett & Gurwitz (1970) also reported sexdifferences in feeding behaviour although withinthe context of formula feeding. They increased thesweetness of formula fed to newborns and foundfemale and heavier infants consumed significantlymore sweetened formula than male or lighterinfants. In a second experiment, the researchersmanipulated the size of the hole in the bottle teat,alternating feeds of standard formula with a regularand a small hole. Consumption by boys was notaffected by the small hole, although that of femaleand heavier babies was reduced. The findingssuggest that female and heavier infants may bemore responsive to sweetness or, possibly, are moreable to detect this. Female and heavier infants mayalso be less willing to expend energy on feedingwhen this is made more difficult.
Infant feeding behaviour norms
A number of studies have examined normative aspectsof infant feeding such as intake and duration of feeding.These provide contextual information that is helpful inunderstanding feeding behaviour and the expression offeeding cues in infancy. In an observational study oftoddlers, Parkinson &Drewett (2001) found that meanmeal duration across two observed meals was approxi-mately 19min with a mean intake of 165g. However,within these parameters, the authors found a highdegree of variability across individuals and meals. Theyfound meal duration and intake were not significantlycorrelated, but instead, intake increased significantlywith number of bites. Number of bites therefore maybe a better indicator of level of hunger in toddlers thanmeal duration.
Infant and toddler feeding norms were also investi-gated by Reau et al. (1996). They asked mothers aboutduration and enjoyment of eating, food refusal and eat-ing speed. Mean reported feeding duration did notdiffer significantly across age, birthweight or birthorder; 90% of infants and toddlers were reported tofinish a meal in less than 30min. Food refusal, however,was commonly reported in toddlers, indicating that thisis not necessarily a satiation cue but rather a develop-mentally typical eating behaviour in toddlers.
Young & Drewett (2000) conducted observationalresearch into toddlers’ eating behaviour. Their workprovides particular insights into feeding behaviour inthe contexts of savoury and sweet courses. Medianintake for desserts and mains was similar (71 and 82 g,respectively), although median durations were 5 and10min, respectively. Furthermore, median number offood refusals for sweet courses was around half thatfor the main course, indicating that the childrenconsumed desserts more quickly and with fewerrefusals than in main courses despite already beingpartly satiated.
Other observational research into infant eating pat-terns was carried out by Van Dijk et al. (2009), in thiscase in the specific context of weaning. They foundconsiderable variability within individuals in terms offood refusal, intake and meal duration. As might beexpected, this variability was greatest in the earliestspoon feeding sessions. The average duration of mealswas relatively constant (8 to 10min across the 3-month
220 J. McNally et al.
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period observed). Consumption, however, increasedduring the first 12weeks of weaning, while refusaldecreased. This study provides further evidence thenthat developmental stage impacts on behaviours associ-ated with hunger and satiation.
The impact of milk composition and feeding method on infantfeeding behaviour
While Paul et al. (1996) and Llewellyn et al. (2011)reported incidental differences in feeding behaviouraccording to feeding method, two studies have exam-ined relationships between feedingmethod and feedingbehaviour more directly.
It has been proposed that differences betweenbreastfed and formula-fed infants in growth velocityand in the experience of hunger and satiation may beattributable in part to milk composition. Breast milkdiffers from formula in amount and form of amino acidcontent, and this may play a role in the faster weightgain recorded in infants fed cow’s milk formula com-pared with breast milk. Because free amino acids suchas glutamate are implicated in satiation in both animaland human studies, Ventura et al. (2012) manipulatedmilk composition to examine its effects on intake andsatiety. They fed infants a standard cows’milk formula,a high free glutamate formula or a cow’s milk formulafortified with free glutamate. Infants consumed signifi-cantly less of the high free glutamate formula and thefortified cows’milk formula than the regular cow’s milkformula. The authors also examined the effect of for-mula composition on satiety (determined by the effectof the first meal on later consumption). They found sig-nificantly higher levels of satiety after consumption ofthe high free glutamate formula and the fortified cows’milk formula than standard cow’s milk formula.
The impact of milk composition on feeding behav-iour is also evident in research by Wright et al. (1980)in relation to breast milk and formula milk. Theseauthors video-recorded three feeding sessions atmonthly intervals from birth to 2months in bothformula and breastfed infants. Mothers also kept feed-ing diaries. Breastfed babies exhibited pauses insucking while feeding, whereas formula-fed infantsfed almost continuously. The authors also identified di-urnal variations in the size of feed consumed bybreastfed infants, with early morning feeds being the
largest of the day. This may represent a diurnal varia-tion in breastmilk composition or in the hunger or thirstof breastfed babies; however, it was not observed informula-fed babies. Feeding method (breastfeeding orformula) therefore appears to impact both on feedingbehaviours and patterns of hunger.
Food preferences and infant feeding behaviour
Several studies suggest that hunger and satiation arenot the only drivers for infant consumption but thathedonic responses to food also play a role. Mennellaet al. (2009) investigated acceptance of cereal flavouredwith breast milk, cow’s milk formula and hydrolysedcasein formulas (HCFs) in 4- to 9-month-old infants.HCFs have stronger savoury, bitter and sour tastes thanbreastmilk or cow’s milk formula, and the investigatorsfound that infants previously fed on these ate signifi-cantlymore savoury, sour and bitter tasting cereals thanthose breastfed or fed cow’s milk formula. Mennellaet al. (2009) also assessed liking of the cereals via theFacial Action Coding System (Ekman & Friesen,2002). Infants in this study showed fewer negative facialexpressions (e.g. brow lowering, nose wrinkling andsquinting) than the other groups. Thus, enjoyment oftaste (shown through facial expression) was signifi-cantly associated with amount consumed.
Food preference research has examined flavour aswell as taste preference. Mennella et al. (2001) exam-ined liking of carrot flavour in breastfed infants ofmothers who drank carrot juice or water during preg-nancy and lactation. Infants with previous exposure tocarrot flavour in utero or through breastfeeding showedfewer negative facial expressions and greater enjoy-ment of carrot juice-flavoured cereal (rated bymothers) than those without prior exposure. Amountconsumed and meal duration showed a similar trend,but these were not significant. In terms of food flavour(rather than taste), infants may communicate liking ordislike through facial expression more than intake oreating duration.
While several studies have examined taste andflavour preferences in infancy, the impact of texturepreference on eating has been reported by Blossfieldet al. (2007). They used mothers’ ratings to assessenjoyment of chopped or pureed carrots in toddlers.
Hunger and satiation in the first 2 years of life 221
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Previous experience with different textures was thestrongest predictor of enjoyment of the choppedcarrots and was also associated with amount consumed.This again suggests that amount consumed and eatingduration are driven by enjoyment as well as hunger.
As noted previously, Skinner et al. (1998) examinedthe expression of infant and toddler food preferencesalongside other mealtime communication behaviours.They did so using open-ended questions to explorehow mothers identified food preferences in theirinfants. Mothers identified behaviours such as openingthe mouth readily as the spoon approached andconsuming a large amount, as indications of liking,while dislike was judged through facial expression andbody movements (throwing food and head turning).
Discussion
The purpose of this review was to consider the evi-dence regarding infants’ feeding cues, along withfactors that affect the expression and perceptionof these. The review revealed that feeding cuesand behaviours are shaped by numerous issues. Thesecan be conceptualised in terms of individualpsychological factors, infants' physical attributes and
environmental factors (Fig. 2). It is important to note,however, that many of these factors are inter-connected; e.g., psychological factors such as foodpreference influence consumption but are influencedthemselves by environmental factors such as exposure(Mennella et al. 2001; Blossfield et al. 2005) and otherindividual psychological factors such as temperament(Forestell & Mennella 2012).
Infant feeding cues and feeding behaviour
Maternal reports indicate that mothers use many cuesto assess hunger and satiation (Skinner et al. 1998;Anderson et al. 2001; Hodges et al. 2008). Both generaland specific cues may indicate hunger and fullness(Hodges et al. 2008), and there are indications that cuesvary in form and intensity and with developmentalstage (Hodges et al. 2008; Hodges et al. 2013; Skinneret al. 1998). Notwithstanding insights from maternalreports, this literature is relatively small. In addition,the heterogeneous aims and contexts of different stud-ies confound attempts to draw simple conclusions:Anderson et al. (2001) examined the specific contextof weaning, while Hodges et al. (2013) investigatedresponsive feeding. Studies differ also in the amountof detail provided regarding feeding cues and in the
Fig. 2. Main influencing factors on feeding behaviour in the first 2 years of life (established connections in solid lines, impact of individual factors on appetiteand interactions between factors in broken lines).
222 J. McNally et al.
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methods used to investigate feeding.Only Skinner et al.(1998) and Hodges et al. (2008) provided detailedinformation regarding feeding cues and details ofdevelopmental aspects of hunger and satiationbehaviours. Meanwhile, only Skinner at al. (1998)employed a longitudinal approach, and only Hodgeset al. (2013) developed a validated tool for observinghunger and fullness cues (the RCFCS). This, however,is not primarily concerned with tracking cues so muchas measuring responsive feeding.
Observational studies of infants in controlled con-ditions suggest that different motor and suckingbehaviours are indicative of hunger and satiation(Lew & Butterworth, 1995; Turkewitz et al. 1966;Paul et al. 1996) and vary with infant age(Paul et al. 1996). Such research provides insightsregarding fine details of hunger and satiation behav-iours that are less apparent in maternal reports.However, the research in this area has limitations.Again, the literature is small. There are also methodo-logical questions with some papers failing to reportissues that may bias results, e.g. observer blindness toexperimental condition (Lew & Butterworth 1995;Turkewitz et al. 1966). Only Paul et al. (1996)observed the same infants over an extended period(i.e. months rather than days), and only they com-pared behaviours before and after feeding with thoseduring feeding.
Alongside the observational work conducted in con-trolled conditions, Young &Drewett (2000), Parkinson&Drewett (2001) and Van Dijk et al. (2009) conductedobservations of normative infant eating behaviour innaturalistic settings. Meanwhile, Reau et al. (1996)investigated normative feeding behaviour using surveymethods. It is a relative strength that the feeding normsliterature includes both observational and longitudinalenquiry. Furthermore, evidence from these studies isgenerally consistent regarding ‘gross’ aspects of feedingbehaviour such as meal duration, intake and the impactof developmental changes on feeding. They also indi-cate that behaviours such as food refusal (which mightbe perceived as satiation) are common, particularly attransition points such as weaning. Studies of infantfeeding norms therefore have implications for under-standing the contextual parameters of feeding cues ininfants. Moreover, in the case of Young & Drewett
(2000), they provide insights into the impact of differentkinds of food (savoury vs. sweet) on eating behaviour.
Individual psychological factors
An important indication from several studies is thekey role mothers play in interpreting feeding cues.Crucially, this highlights the dyadic nature of feed-ing interactions. As noted, mothers’ interpretationof cues is not based solely on infant behaviour butalso infant characteristics and external cues such astime (Anderson et al. 2001; Hodges et al. 2008).Importantly, studies indicate that hunger cues aremore salient to mothers than satiation cues (Hodgeset al. 2013). The role of mothers in interpretingfeeding cues is also evident in associations betweenmaternal characteristics and how feeding cues areperceived. In particular, maternal characteristicssuch as obesity appear to be associated with lowerresponsiveness to infant fullness (Hodges et al.2013).
Evidence suggests that infant temperament mayinfluence feeding behaviour in terms of enjoymentof novel foods or intake of food (Darlington &Wright 2006; Wasser et al. 2011; Forestell & Mennella2012; McMeekin et al. 2013). Most studies in this areahave been concerned with associations between tem-perament and weight gain or temperament and ma-ternal feeding practices. Several explanations mayaccount for these associations, making it difficult todraw simple conclusions. Darlington and Wright’s(2006) finding that infants with high distress to limita-tions gained weight quickly may be explained in rela-tion to maternal responses to these babies. Infantswith high distress to limitations were reported tosleep less and to fuss more, and may have receivedadditional feeds to comfort them. This interpretationis supported by McMeekin et al.’s (2013) finding thatmothers of difficult infants were more likely to feedthem as a soothing strategy. Alternatively, mothersin Darlington et al.’s (2006) study may have feddemanding babies more as a result of misinterpretingfractiousness as hunger. A further possibility is thatthis group of infants may simply have been more hun-gry and demanding because of rapid growth (Darlington& Wright 2006).
Hunger and satiation in the first 2 years of life 223
© 2015 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd. Maternal & Child Nutrition (2016), 12, pp. 205–228
Darlington and Wright’s (2006) finding that infantswith high fearfulness scores showed slower weight gainis harder to explain. The authors suggest such infantsmay have difficulty expressing their needs, althoughno evidence is provided for this. The precise mecha-nisms behind associations between temperament andinfant weight therefore remain unclear. The picture isfurther complicated by findings that maternal charac-teristics may shape responses to infants withdemanding temperaments (Darlington & Wright,2006; Wasser et al. 2011). While these findingsconfound attempts to identify causal relationshipsbetween infant feeding and infant temperament, theyagain highlight the bidirectional nature of feedinginteractions.
A further difficulty in interpreting the infant tem-perament and feeding behaviour literature arisesfrom differences in study characteristics (Bergmeieret al. 2014). Different temperament measures wereused by McMeekin et al. (2013) from those usedby Darlington & Wright (2006) and Wasser et al.(2011) (the STSI and the IBQ, respectively). Fur-thermore, infants in Darlington’s study were youn-ger than those in Wasser et al.’s (2011) andMcMeekin’s (2013) research (8–12 and 8–72weeks).In addition, the cross-sectional nature of muchresearch to date limits how far conclusions can bedrawn regarding associations between infant tempera-ment and weight gain.
The impact of physical characteristics
As discussed, infant age appears to affect how feed-ing cues are expressed, while Llewellyn et al.’s(2012) twin study provides evidence that appetitivebehaviours are also determined in part by genotype.Llewellyn et al.’s (2011) large scale study of infantappetite lends credibility to the idea that character-istics such as sex and birthweight influence appetiteand therefore the expression of hunger and satia-tion. There is additional evidence that characteristicssuch as sex, birthweight or prematurity influencefeeding behaviours and potentially feeding cues(Nisbett & Gurwitz 1970; Hwang, 1978; Wright1986, Stevenson et al. 1990). Such studies involveddirect observation with appropriate procedures
taken in relation to this (inter-rater reliability andobserver blindness). This is a relative strength.However, findings from some studies have beenbrought into question by more recent research. Sim-ilar levels of breastmilk consumption by males andfemales led Wright (1986) to conclude that reportsof different hunger cues in male and female infantsarose from maternal perceptions rather than infantbehavio
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