Infant Development, feeding skills, and relationships

• What factors influence food choices, eating behaviors, and acceptance?

Sociology of Food

• Food Choices– Availability– Cost– Taste– Value– Marketing Forces– Health– Significance

Sociology of Food

• Hunger• Social Status• Social Norms• Religion/Tradition• Nutrition/Health

Taste and Smell

• Initial experiences of flavors occur prior to birth

• Amniotic fluid flavors--- maternal diet• Breast milk odor/flavor-- maternal diet• Sweet preference (Lactose)

– More frequent and stronger sucking behavior in response to sucrose

– Ability to detect other flavors (ie salt) emerges later (~ 4 months)

Mechanisms of Appetite Regulation

• Poorly and incompletely understood• Genetics• Pleasure-seeking and hedonic responses to feed intake

are mediated by humoral substances (endorphins, dopamine, etc)

• Interaction between hormones, nutrients, and neuronal signals with the CNS

• Appetite stimulus: ghrelin• Appetite inhibition: CCK, leptin, GLP-1 etc)• GI volume sensitive feedback loops (ie distention)

The feeding relationship

• Nourishing and nurturing

• Supports developmental tasks

• Learning

• Relationship • Development• Emotion and

temperament

Relationship

• Feeding is a reciprocal process that depends on the abilities and characteristics of both caregiver and infant/child

Relationship

• The feeding relationship is both dependent on and supportive of infants development and temperament.

Relationship

• Children do best with feeding when they have both control and support

Healthy Feeding Cycle

• Child associates hunger with need to eat

• Child communicates need• Parent reads cues and provides• Child communicates satiety• Parent responds• Positive experience gained

• Parent anticipates physical needs

Tasks

• Infant– time– how much– speed– preferences

• Parent– food choices– support– nurturing– structure and limits– safety

Infant and Caregiver Interaction

• Readability

• Predictability

• Responsiveness

Development

• Oral- Motor development

• Neurophysiologic development• Homeostasis• Attachment• Separation and individuation

• Oral-motor development parallels psychosocial, neurophysiologic milestones of homeostasis, attachment, and separation/individuation

Development of Infant Feeding Skills

• Birth– tongue is disproportionately large in comparison with

the lower jaw: fills the oral cavity – lower jaw is moved back relative to the upper jaw,

which protrudes over the lower by approximately 2 mm.

– tongue tip lies between the upper and lower jaws. – "fat pad" in each of the cheeks: serves as prop for

the muscles in the cheek, maintaining rigidity of the cheeks during suckling.

– feeding pattern described as “suckling”

Development of Feeding Behavior

Age Reflexes Behavior

B-3 months Root, suck-swallow-breath

Suckling pattern of feeding

4-6 months Fading root/bite reflex Mature suck, brings objects to mouth, munching pattern

7-9 months Normal gag development

Munching, rotary chewing, sits alone, holds bottle alone

10-12 months Bites, brings food to mouth, drinks from cup, spoon feeds

Age (months)

Development Feeding/oral sensorimotor

Birth to 4-6 Visual fixation and tracking, learning to control body against gravity, sitting with support near 6 months, rolling over, hand to mouth

Nipple feeding, hand on bottle (2-4 months), maintains semiflexed posture during feeding, promotion of infant-parent interaction

6-9 Sitting independently for short time, mouthing hand and toys, extended reach with pincer grasp, object permanence, stranger anxiety, crawling skills emerging

Feeding more upright position, spoon feeding smooth purees, suckle pattern-- suck, both hands hold bottle, finger feeding introduced, vertical munching, preference for parental feeding

9-12 Pulling to stand, cruising, first steps by 12 months, some independent spoon feeding, refining pincer grasp

Cup drinking, eats lumpy/mashed foods, finger feeding, chewing includes rotary jaw action

12-18 Refining gross and fine motor skills, independent walking, climbing stairs, running, grasping and releasing with precision

Self feeding, grasps spoon with whole hand, 2-handed cup holding, drinking with 4-5 consecutive swallows, holding and tipping cup

Stages of Development

• Homeostasis

• Attachment

• Separation and individuation

Stages

Age Development

1-3 months Homeostasis * State regulation

* Neurophysiologic stability

2-6 months Attachment * “falling in love”

* Affective engagement and interaction

6-36 months

Separation and individuation

* Differentiation

* Behavioral organization and control

Homeostasis

• Infant cycles through physical states

• Parent provides a safe and comfortable environment

• Reflex feeding transforms to self regulation of hunger

Attachment

• Emotional/social interactions

• Parent reciprocates/engages

• Infant’s emotional and physical needs reinforced

Separation

• Struggle for autonomy

• Parent supports autonomy and guides daily structure

• Emotional needs distinguished from physical needs

Stage

Homeostasis

Birth to 3 months

Cues for feeding: arousal, crying, rooting, sucking

Caregiver responds to cues ( leads to self regulation.

Infant quiets to voice

Hunger-satiety pattern develops

Infant smile promotes interation

Pleasurable feeding experience--greater environmental interaction

Attachment:

3-6 months“Falling in love”

↑ reciprocity

Consistent cues, anticipation of feeding. Social pauses vs satiety of ? Burping, parents preferred feeder, attention seeking behavior

Separation I Individuation:

6-36 months

Responds to “no”, imitation, exploration play, follows simple directions, self independent feeding emerges, speech/language development,

Emotion/Temperament

• Temperament theory categorizes enduring personality styles based on activity, adaptability, intensity, mood, persistence, distractibility, regularity, responsivity, approach/withdraw from novelty

Chess and Thomas 1970

Temperament

• Easy: approaches novelty, positive mood, adaptable, regular, active, low intensity

• Slow to warm: withdraws from novelty, low mood, low activity, moderate to low intensity, cautious

• Difficult: withdrawing, low adaptability, high intensity, low regularity, negative mood

Play, Learning, Exploration

Feeding Difficulties

Stage Feeding difficulty

Homeostasis Poor growth, stressful-unsatisfactory feeding, “colic”

Attachment Vomiting, diarrhea, poor weight gain, intensely conflicted or disengaged interactions

Separation-Individuation Food refusals

Feeding Difficulties

• Complex problems caused by multiple factors within the lives of infants, children, and adults.– Medical/physical– Neurodevelopmental– Behavioral– Interact ional– Environmental– Psychosocial

Why Baby Won’t Eat

• Case reports of FTT/inadequate intake without any identifiable etiology

– Tolia, et al

• Problems established early in feeding persist into later life and generalize into other areas

• Ainsworth and Bell– feeding interactions in

early months were replicated in play interactions after 1st year

• The Mother-Infant Feeding Relationship Across the First Year and the Development of Feeding Difficulties in Low-Risk Premature infants: Dalia Silberstein et al

– Infancy 14(5) 501-525 2009

Silberstein

• N= 76

• Mother-Infant Observation 2-3 days prior to hospital discharge, 4 months corrected age, and 1 year corrected age

• Difficult vs non difficult feeders– Greater maternal gaze aversion, less

adaptability, less affectionate touch during play interactions, more intrusive at 1 year

Factors to consider

• Medical

• Developmental

• Temperament

• Psychosocial

• Nutritional

• Environmental

Feeding

• Delays in feeding skills

• feeding intolerance

• behavioral

• medical/physiological limitations

• other

Feeding DifficultiesRelated to maturity, medical and

neurodevelopmental status

• State control• endurance• suck-swallow-breath coordination• sleep-wake cycles• cues and demand behavior• temperament• patterns of oral-motor development

The Complexity of feeding problems in 700 infants and young children Presenting to a

Tertiary Care Institution• Rommel et al: J Ped Gastro and Nutrition,

July 2003

• Multidisciplinary Assessment catagorized feeding problems:– 86.1% medical– 61% oropharangeal dysfunction– 18.1% behavioral

Rommel et al

• Medical/oral-motor – occurred more often <2 years of age

• Behavioral– occurred more often >2 years of age

Rommel et al

• Single identified problem

– 26.7% medical– 5.2 % oral/motor– 5.4% behavioral

Rommel et al

• Multifactorial– 48.5% oral/medical– 1.5% oral/behavioral– 5.2% medical behavioral