Received: 25 June 2019 

|
  Revised: 3 February 2020 
|  Accepted: 10 February 2020

DOI: 10.1111/ipd.12628

ORIGINAL ARTICLE

Impact of problematic eating behaviour and parental feeding

styles on early childhood caries

Harsha V. Nembhwani  | Jasmin Winnier

Department of Pedodontics and Preventive

Dentistry, School of Dentistry, D.Y.Patil
Deemed to be University, Navi Mumbai,
India
Correspondence
Jasmin Winnier, Department of
Pedodontics and Preventive Dentistry,
School of Dentistry, D.Y.Patil Deemed
to be University, Nerul, Navi Mumbai,
Maharashtra, India.
Email: jasmin.winnier@dypatil.edu
Abstract
Background: Eating behaviour in childhood has been implicated in development of
early childhood caries. Parenting feeding styles can also contribute to development
of various eating behaviours.
Aim: To evaluate relationship between children's eating behaviour and parental
feeding styles with ECC in preschool children.
Design: A case-control study was conducted in 440 children who were selected and
divided into 2 groups: Group A—children with ECC and Group B—children without
ECC. Dental caries was recorded using dmft index. The parents of children in both
groups were requested to complete the Children's Eating Behaviour Questionnaire
(CEBQ) and Parental Feeding Style Questionnaire (PFQ).
Results: There was positive association of food avoidance subscales of CEBQ
(Satiety Responsiveness, Food Fussiness, Slowness in Eating, and Emotional
Undereating) along with certain food-approaching subscales (Desire to Drink and
Emotional Overeating) with dental caries status. It was also seen that parental feed-
ing patterns such as Encouragement and Instrumental feeding contributed to decrease
in dental caries of the child when compared to Control and Emotional feeding.
Conclusion: Certain eating and feeding behaviours can possibly be associated with
development of ECC, such behaviours can be successfully identified using CEBQ
and PFQ.

KEYWORDS
children's eating behaviour questionnaire, early childhood caries, Parental feeding style questionnaire

1  |   IN T RO D U C T ION of ECC was reported to be 49.6%.3 There is an increasing

Early childhood caries (ECC) is clinically defined as the
presence of one or more decayed (non-cavitated or cavi-
tated lesions), missing (due to caries), or filled surfaces, in
any primary tooth of a child under age six.1 The prevalence
of ECC is reported to be 41% in the United States American
Academy of Pediatrics, 2009 (Centers for Disease Control
and Prevention, 2005a).2 In India, the overall prevalence
awareness that problematic eating behaviour which mani-
fests in early childhood may be a precursor of abnormal
eating in later life.4 Extensive literature is available on eat-
ing disorders like anorexia nervosa and bulimia but eating
disorders in childhood have not gained much attention. The
effects of problematic eating behaviour in childhood such
as slowness in eating, pouching of food for prolonged peri-
ods, and selective eating has been reported to have a direct

© 2020 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Int J Paediatr Dent. 2020;00:1–7.  |

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2       HARSHA and JASMIN
correlation with the increasing prevalence of early child-
hood caries (ECC).5 This aspect, however, is relatively un-
explored; hence, further research is required in this regard.
Thus, the eating behaviour of preschool children was as-
sessed in this study.
For a very young child, parents play a major role in de-
termining the type of food consumed by the child. The diet
and nutrition that the parent provides may also be dependent
on the type of parental attitude towards the diet.6 Hence, the
feeding behaviour of the parent was also assessed in this
study.
Thus, the objective of the study was to assess the relation-
ship between children's eating behaviour and parental feeding
styles with ECC in preschool children.
2  |  M AT E R IA L S A N D ME T HOD
A case-control study was conducted to assess the problem-
atic eating behaviour (PEB) and parental feeding styles (PFS)
among 3- to 6-year-old preschool children and its association
with early childhood caries (ECC). This study is reported ac-
cording to STROBE guidelines.
2.1  |  Location and setting
Preschool children enrolled in Public schools in Navi
Mumbai, India, were recruited for the study after obtain-
ing permission from the school authorities and the parents.
The study was conducted in the Department of Pediatric
and Preventive Dentistry, DY Patil University School of
Dentistry, Navi Mumbai.
2.2  |  Eligibility criteria
Healthy cooperative children between 3 and 6  years of
age with no systemic diseases were included in our study.
Children with history of allergy to food products, who were
under long-term medications and those un-cooperative for
dental examination, were excluded from the study.
2.3  | Calibration
The study was conducted by a single examiner. Thirty chil-
dren between 3 and 6  years of age, who reported to the
Department of Pediatric and Preventive Dentistry, DY Patil
School of Dentistry, Navi Mumbai, were examined for early
childhood caries by the principal examiner and a gold stand-
ard. The same children were re-examined after 1  week to
assess intra-examiner agreement. The kappa statistic was
Why this paper is important to paediatric
dentists
• Both eating and feeding behaviours should be as-
sessed in the routine dental check-up.
• Food Approach behaviour has shown to decrease
the caries status whereas the Food Avoidance be-
haviour leads to an increase in the dental caries.
• Parental Feeding behaviour—Encouragement also
contributes to the decrease in dental caries.
used for the determination of intra-examiner agreement
(k = 0.80). The examined children were not included in the
main study.
2.4  |  Pilot study
A pilot study was conducted between February and March
2017 which included 50 children with ECC (cases) and
50 children without any evidence of ECC (controls) who
were matched according to age and gender. The Children's
Eating Behaviour Questionnaire (CEBQ) and Parental
Feeding Style Questionnaire (PFQ) were assessed to de-
termine the feasibility of study. The Content validity of
the questionnaire was evaluated by a panel of six senior
dental professionals. The aim was to illustrate those items
with a high degree of agreement among the professionals.
Aiken's V was used to quantify the agreement between the
experts, and the value obtained was 0.82. Modifications
in the wording of certain questions were recommended by
the panel. In order to assess the reliability of questions,
similar questions were grouped and Cronbach's alpha was
calculated. The correlations between the items ranged from
0.72 to 0.80. Significant findings were obtained with both
questionnaires and ECC. Hence, both the questionnaires
were used in our study. The study was conducted in Navi
Mumbai, Maharashtra, India from May 2017 to December
2017.
2.5  |  Sample size determination
The sample size was calculated using the following formula:
( )( )2
𝜅 ∗ 𝜎12 + 𝜎22 z1−𝛼∕2 + z1−𝛽
n2 =
Δ2
( 2 ) ( )2
𝜎1 + 𝜎22 ∕𝜅 z1−𝛼∕2 + z1−𝛽
n1 =
Δ2
HARSHA and JASMIN   
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|
Considering the difference in group means to be 20%, T A B L E 1   Gender wise distribution of the study participants
power of the study as 80%, at 95% confidence interval, a ratio among both the groups using chi-square test
of sample size (group I/ group 2) as 1 and with the signifi- Gender
cance level set at 5%, a sample size of 440 was obtained (ie
  Male Female Total
220 in each group).
Group
Without ECC
2.6  |  Data collection Count 144 76 220
% within Group 65.5 34.5 100.0
The study was approved by the institutional ethical com- With ECC
mittee. Informed consent was obtained from the parents and
Count 128 92 220
children involved. A total of 1005 healthy children between 3
% within Group 58.2 41.8 100.0
and 6 years attending public schools in Navi Mumbai, India,
Total
were screened for their dental caries status by a single exam-
iner. The children were divided into 2 groups: Group A— Count 272 168 440
children with ECC and Group B—children without ECC. % within Group 61.8 38.2 100.0
Approximately 3-5 of the selected children were appointed Chi square value: 2.465, P value: .116
every day to the DY Patil School of Dentistry for a com- *P < .05—Significant.
plete dental examination for the presence of decayed missing **P < .001—Highly significant.
filled teeth (dmft) and decayed missing filled surfaces with
the help of a mouth mirror and blunt probe. The Children's between children with and without ECC with respect to the
Eating Behaviour Questionnaire and Parental Feeding Style Factor 1—Control and Factor 4—Emotional feeding styles
Questionnaire were administered to parents of the children of PFQ. There was also a statistical significant difference
examined under the supervision of the principal investigator. between both the groups in relation Factor 2—Instrumental
All the collected data were subjected to statistical analysis. feeding style of PFQ (Table 3).

2.7  |  Statistical analysis 4  |  DISCUSSION

The collected data tabulated in Microsoft Excel 2007
and were analysed using IBM SPSS statistics 20.0 (IBM
Corporation, Armonk, NY, USA) with statistical significance
set at P < .05. The relation between CEBQ, PFQ, and ECC
was assessed using the unpaired t test.
3  |   R E S U LTS
Of the total 440 participants, 272 were males and 168 were
females. There was no statistical significance between the
groups with respect to the gender (Table 1). On assess-
ing the relation between problematic eating behaviour and
early childhood caries (ECC), it was seen that there was a
highly statistical significant difference between children
with and without ECC with respect to the Factor 1—Food
Responsiveness (FR), Factor 5—Satiety Responsiveness
(SR), Factor 7—Emotional Undereating (EUE), and Factor
8— Food Fussiness (FF) of CEBQ. There was also a statisti-
cal significant difference between both the groups in rela-
tion to other factors such as Factor 2—Emotional Overeating
(EOE) and Factor 4—Desire to Drink (DD) of CEBQ (Table
2). When comparing the parental feeding styles with ECC, it
was observed that there was a statistical significant difference
The prevalence of mother perceived feeding and eating be-
haviours in children are reported to be 21%-33%.7 Previous
studies have shown that 53% of mothers felt that their child
avoids certain food and 34% mothers reported that their
child eats selectively.8This study was conducted to evaluate
whether such problematic eating behaviour may be a predic-
tor for ECC. In our study, the children between 3 and 6 years
were selected since in this age group the primary dentition is
complete.9 Children below 3 years were not included because
of the possible behavioural problems that might hinder com-
plete examination of the oral cavity.
The children with known allergy to any kind of food
products were excluded from the study due to their possible
dietary restriction. Also the children with significant medi-
cal history, mental or physical disability or under long-term
medications were excluded because of the poor dietary habits
and intake of sucrose containing medications that will predis-
pose in the formation of early childhood caries.10,11
In this study the DEFT/deft and DMFS/dmfs index was
used to record the caries status since they can be easily ad-
vocated for examination of a larger population with limited
armamentarium. It is relatively simple, less time consuming
and has been practised successfully in many survey popula-
tions.12,13 The indices were recorded using mouth mirror and
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4       HARSHA and JASMIN

T A B L E 2   Comparison of CEBQ factor values in terms of (Mean (SD)) among both the groups using unpaired t test

Variables Group N Mean Std. deviation t value P value

CEBQ-Factor 1 (FR) Without ECC 220 13.81 1.894 9.905 <.001**
With ECC 220 11.15 3.502
Factor 2 (EOE) Without ECC 220 4.62 0.682 7.372 .018*
With ECC 220 6.39 3.501
Factor 3 (EF) Without ECC 220 13.56 1.806 5.151 <.001**
With ECC 220 11.30 6.235
Factor 4 (DD) Without ECC 220 4.80 1.150 6.395 .002*
With ECC 220 6.91 4.766
Factor 5 (SR) Without ECC 220 10.59 1.566 6.582 <.001**
With ECC 220 12.72 4.552
Factor 6 (SE) Without ECC 220 11.61 1.605 0.204 .838
With ECC 220 11.55 4.679
Factor 7 (EUE) Without ECC 220 3.88 0.708 7.386 <.001**
With ECC 220 5.92 4.046
Factor 8 (FF) Without ECC 220 14.75 2.137 4.886 <.001**
With ECC 220 17.13 6.923
*P < .05—Significant.
**P < .001—Highly significant.

T A B L E 3   Comparison of PFQ factor values in terms of (Mean (SD)) among both the groups using unpaired t test

Variables Group N Mean Std. deviation t value P value

C (control) Without ECC 220 25.05 1.936 3.379 <.001**
With ECC 220 26.82 7.538
I (instrumental) Without ECC 220 13.58 1.234 2.168 .031*
With ECC 220 12.70 5.872
EN (encouragement) Without ECC 220 27.63 2.915 0.942 .347
With ECC 220 27.20 6.140
EM (emotional) Without ECC 220 12.23 2.055 11.145 <.001**
With ECC 220 15.63 4.038
*P < .05—Significant.
**P < .001—Highly significant.

a blunt probe under natural or artificial light. A blunt probe
was used to avoid possible damage to the enamel surface, to
remove food debris, and to gain better visual access to the
tooth.
There are various questionnaires available in the litera-
ture to evaluate the eating behaviour of children which have
taken into account a wide range of age.14,15 In our study, the
Children's Eating Behaviour Questionnaire (CEBQ) was
used to evaluate the eating behaviour of the children. The
CEBQ was proposed by Wardle J et al in 2001. It was devel-
oped and validated for assessing the eating behaviours and
its relation to body mass index (BMI) of children between
3 and 8 years of age. It is a parent-reported questionnaire
which recorded a range of dimension of eating styles. The
author included different eating styles such as food respon-
siveness, food enjoyment, desire to drink, food fussiness,
emotional overeating and emotional undereating, satiety
responsiveness, and slowness in eating. Large pools of
constructs were developed, and finally, it was cut down to
a 35 item questionnaire with 8 scales with good validity
and retest reliability.16 The CEBQ is regarded as the most
detailed tool for evaluating the eating behaviour of chil-
dren and has also been validated in Portuguese sample.17 It
was also reported to be an efficient tool to evaluate eating
behaviour in children.18 This instrument has been success-
fully used to establish the relationship between ECC and
HARSHA and JASMIN
the eating behaviour of children between 3 and 6 years of
age in a study by Anandakrishna et al in 2014.5
The parental feeding styles were evaluated using the
Parental Feeding Questionnaire (PFQ) in our study. It was
developed by Wardle et al in 2002, and it has been proved
to be a reliable instrument for addressing the parental feed-
ing patterns and obesity in children. It is a 27 item question-
naire that is grouped into 4 factors—Control, Instrumental,
Encouragement, and Emotional.6 The relationship between
parental feeding styles and early childhood caries has not
been researched upon, and thus in our study, we attempted
to evaluate parental feeding styles and its relationship with
ECC.
For this study, 1005 children between 3 and 6 years of age
were examined and their deft and dmfs was recorded. Of the
all examined children, 440 children were selected depending
on the inclusion and exclusion criteria. They were equally
distributed into two groups: Group A—children with ECC
and Group 2—children without ECC. After the examination,
the parents were requested to complete the CEBQ and PFQ
forms.
4.1  |  Children's eating behaviour and its
relation to ECC
The 1st factor of CEBQ is Food Responsiveness (FR); previ-
ous studies have reported that increased Food Responsiveness
was positively associated with obesity in children. In our
study, it was seen that when Food Responsiveness increases
there is decrease in the deft status of the child. This result was
in contradiction with the study conducted by Anandakrishna
et al (2014) where they found a significant relation with the
children always keeping food in their mouth and ECC when
compared in with children without ECC.5 The difference in
the results could be probably because in the previous study,
every question was assessed individually, and only one ques-
tion was found to be associated with ECC. When the entire
factor, however was considered, a positive food responsive-
ness was associated with decreased deft.
On assessment of Emotional Overeating (EOE), it was
seen that deft increased significantly when the children had
increased EOE. This result was in accordance with the study
conducted by Anandakrishna et al (2014) who reported pres-
ence of ECC was significantly high in children who ate more
when they had nothing else to do when compared to those
who did not eat more.5
When Enjoyment of Food (EF) was assessed in this study,
we noted that children without ECC enjoyed their food more
when compared to children with ECC and this difference was
statistically significant.
On comparison of Desire to Drink (DD) in children with
and without ECC it was seen that, the deft increased with the
  
   5
|
increase in consumption of drinks, usually sugar sweetened
drinks. This result is in accordance with the previous stud-
ies where sodapop when compared to 100% fruit juice had
deleterious effect on teeth.19 Similar results were also seen
with the consumption of carbonated soft drinks20-23 or sports
drink.24 Though in our study we did not assess the type of
drink the children preferred, our results indicate that increase
in desire to drink will result in an increase in ECC.
Satiety Responsiveness (SR) is the inability of a child to
have food due to a prior snack or meal. Our study revealed
that deft increased with increased satiety response. This re-
sult was in accordance with the previous studies.19,25
Slowness in Eating (SE) represents the reduction in eating
rate due to lack of enjoyment and interest in food. On com-
parison of slowness in eating in children with and without
ECC, there was no significant difference found in both the
groups.
Emotional Undereating (EUE) reflects the decrease in
eating response as a result of various negative sentiments,
such as sadness, anger, and anxiety. This study revealed that
the deft increased with increased emotional undereating by
the child.
Food Fussiness (FF) is characterized by avoidance of con-
siderable amount of familiar foods as well as ‘new’ foods,
leading to the consumption of an inadequate variety of foods.
We observed that the deft increased with the increased fussi-
ness of the child towards various food intake.
4.2  |  Parental Feeding behaviour and its
relation to ECC
The 1st factor—Parental Control (C), is where the parent has
the control of what, when, and how much should the child
consume. Previous research with relation to obesity has
shown that this kind of feeding behaviour may either lead to
decrease in the obesity of the child because of excessive pa-
rental control, or in some cases, increase in obesity since the
child may lack his self control over consumption of appro-
priate food.6,26 In our study, we observed that deft increased
with the increase in controlled behaviour of the parents to-
wards their children's food intake. The probable reason could
be that, with increased parental control the parent decides
what, when, and how much the child should eat, thus provid-
ing a diet which the child may not enjoy. This will in turn
develop food fussiness which can contribute to the increased
deft of the child.
The 2nd factor, Instrumental (I) Feeding, refers to using
food as reward.6 On comparison of children with and with-
out ECC it was seen that the deft decreases when the par-
ent uses food as a reward for the child. This is similar to
the study by Vandeweghe et al27 who reported that Reward
Responsiveness was positively associated with food approach
 |
6       HARSHA and JASMIN
behaviours that include Enjoyment of food (EF) and Food
Responsiveness (FR) factors of CEBQ.
The 3rd factor, Encouragement (EN), is where the par-
ent encourages the child to try and taste new foodstuffs.
Encouragement to eat derives either from the parent's keen
interest to see the child having food that has been carefully
made or the assumption that a heavier child is healthier.6 On
comparison of children with and without ECC, there was no
significant difference found in both the groups.
The 4th factor, Emotional Feeding (EM), is where the par-
ent uses food to satisfy the emotional needs of the child. It has
been suggested that the children of mothers who eat when
emotionally upset, also have a preference to eat when emo-
tionally disturbed (ie the child's eating behaviour duplicates
the mother's eating style).6 On comparison of children with
and without ECC it was seen that the deft increases when the
parent used food as a source to pacify the emotional needs
of the child. In the assessment of CEBQ also, we observed
that there was an increase in deft with Emotional Overeating
and Emotional Undereating. Thus, it appears that any kind of
emotional feeding or eating behaviour increases the dental
caries status of child.
5  |   CO NC LU SION
Thus, from this study, it can be concluded that the factors
under Food Avoidance subscales of the CEBQ (Satiety
Responsiveness, Food Fussiness, Slowness in Eating, and
Emotional Undereating) along with certain food-approaching
subscales (Desire to Drink and Emotional Overeating) lead to
an increase in dental caries status of the child. It was also seen
that parental feeding patterns such as Encouragement and
Instrumental feeding contributed to decrease in dental caries
of the child when compared to the Control and Emotional
feeding behaviour of parents.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
AUTHORS’ CONTRIBUTION
Substantial contribution to the conception and design of the
work was done by HN and JW. The acquisition, analysis, and
interpretation of data were done by HN. Drafting of data was
done by HN. The proofreading and final approval was done
by JW.
ORCID
Jasmin Winnier  https://orcid.org/0000-0001-9131-3448
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How to cite this article: Nembhwani HV, Winnier J.
Impact of problematic eating behaviour and parental
feeding styles on early childhood caries. Int J Paediatr
Dent. 2020;00:1–7. https://doi.org/10.1111/ipd.12628