1. Infant Development, feeding skills, and relationships

2. What factors influence food choices, eating behaviors, and acceptance?

3. Sociology of Food Food Choices –Availability –Cost –Taste –Value –Marketing Forces –Health –Significance

4. Sociology of Food Hunger Social Status Social Norms Religion/Tradition Nutrition/Health

5. 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)

6. 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)

7. The feeding relationship Nourishing and nurturing Supports developmental tasks Learning Relationship Development Emotion and temperament

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

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

10. Relationship Children do best with feeding when they have both control and support

11. 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

12. Tasks Infant –time –how much –speed –preferences Parent –food choices –support –nurturing –structure and limits –safety

13. Infant and Caregiver Interaction Readability Predictability Responsiveness

14. Development Oral- Motor development Neurophysiologic development Homeostasis Attachment Separation and individuation

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

16. 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”

17. Development of Feeding Behavior AgeReflexesBehavior B-3 monthsRoot, suck-swallow- breath Suckling pattern of feeding 4-6 monthsFading root/bite reflexMature suck, brings objects to mouth, munching pattern 7-9 monthsNormal gag development Munching, rotary chewing, sits alone, holds bottle alone 10-12 monthsBites, brings food to mouth, drinks from cup, spoon feeds

18. Age (months) DevelopmentFeeding/oral sensorimotor Birth to 4-6Visual 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 6-9Sitting 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 9-12Pulling 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 12-18Refining 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

20. Stages of Development Homeostasis Attachment Separation and individuation

21. Stages AgeDevelopment 1-3 monthsHomeostasis* State regulation * Neurophysiologic stability 2-6 monthsAttachment* “falling in love” * Affective engagement and interaction 6-36 months Separation and individuation * Differentiation * Behavioral organization and control

22. Homeostasis Infant cycles through physical states Parent provides a safe and comfortable environment Reflex feeding transforms to self regulation of hunger

23. Attachment Emotional/social interactions Parent reciprocates/engages Infant’s emotional and physical needs reinforced

24. Separation Struggle for autonomy Parent supports autonomy and guides daily structure Emotional needs distinguished from physical needs

25. 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,

26. 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

27. 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

28. Play, Learning, Exploration

29. Feeding Difficulties

30. StageFeeding difficulty Homeostasis Poor growth, stressful- unsatisfactory feeding, “colic” Attachment Vomiting, diarrhea, poor weight gain, intensely conflicted or disengaged interactions Separation-Individuation Food refusals

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

32. Why Baby Won’t Eat Case reports of FTT/inadequate intake without any identifiable etiology –Tolia, et al

33. 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

34. 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

35. 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

36. Factors to consider Medical Developmental Temperament Psychosocial Nutritional Environmental

37. Feeding Delays in feeding skills feeding intolerance behavioral medical/physiological limitations other

38. Feeding Difficulties Related 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

39. 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

40. Rommel et al Medical/oral-motor –occurred more often <2 years of age Behavioral –occurred more often >2 years of age

41. Rommel et al Single identified problem –26.7% medical –5.2 % oral/motor –5.4% behavioral

42. Rommel et al Multifactorial –48.5% oral/medical –1.5% oral/behavioral –5.2% medical behavioral