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PII: S0195-6663(17)30878-4
DOI: 10.1016/j.appet.2017.12.020
Reference: APPET 3728
Please cite this article as: Lumeng J.C., Miller A.L., Appugliese D., Rosenblum K. & Kaciroti N., Picky
eating, pressuring feeding, and growth in toddlers, Appetite (2018), doi: 10.1016/j.appet.2017.12.020.
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Julie C. Lumeng, MD, Alison L. Miller, PhD, Danielle Appugliese, MPH, Katherine Rosenblum,
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Author Affiliations: Center for Human Growth and Development, University of Michigan, Ann
Arbor, MI (JCL, NK, KR, AM); Department of Pediatrics and Communicable Diseases,
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University of Michigan Medical School, Ann Arbor, MI (JCL); Department of Nutritional
Sciences, University of Michigan School of Public Health, Ann Arbor, MI (JCL); Department of
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Health Behavior and Health Education, University of Michigan School of Public Health, Ann
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Arbor, MI (ALM); Department of Psychiatry, University of Michigan Medical School, Ann
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Arbor, MI (KR); Department of Biostatistics, University of Michigan School of Public Health,
Corresponding and Reprint Request Author: Julie C. Lumeng, MD; Center for Human
Growth and Development; 300 North Ingalls Street, 10th Floor; University of Michigan; Ann
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jlumeng@umich.edu
INTRODUCTION
Picky eating is common in early childhood (Dovey, Staples, Gibson, & Halford, 2008)
and is often raised as a concern by parents. Parents can respond to picky eating with pressuring
feeding practices, with the goal of helping the child to overcome picky eating and ultimately
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attain more rapid growth. Although some degree of encouragement of picky eaters is likely
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adaptive and could be viewed as responsive parenting that is sensitive to the child’s needs, other
types of pressure may be maladaptive. Specifically, pressure that is intrusive or not responsive
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to the child is theorized to cause increases in picky eating. In addition, some have theorized that
pressure can overwhelm a child’s healthy internal hunger and satiety cues, leading to excessively
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rapid growth (Dovey et al., 2008; Farrow, Galloway, & Fraser, 2009; Finistrella et al., 2012;
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Gibson et al., 2012; Hayes et al., 2016).
pressuring feeding, and growth, particularly in toddlerhood, would provide valuable practical and
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begins to emerge (Dovey et al., 2008), and therefore during which pressuring feeding and
conflict in the parent-child interaction around food often develops. Pediatric practice guidelines
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include a focus on reducing picky eating (Hassink, 2006) as well as limiting pressure or
excessive control (Barlow & The Expert Committee, 2007). If pressuring feeding that occurs in
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response to a child’s picky eating leads in turn to healthy growth or reductions in picky eating,
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this would suggest that encouraging parents to implement responsive pressure (i.e., pressure that
is not intrusive or excessive) may be a valuable intervention strategy for the child who is a picky
eater and/or has poor growth. If in contrast, pressuring feeding leads to increases in picky eating
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and further slowing of growth, this would suggest that pressuring feeding may not be a
worthwhile strategy for changing the trajectory of children’s picky eating and growth.
Prior studies examining these temporal relationships have mixed results. Specifically,
prior studies have found either no association between pressuring feeding and future markers of
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adiposity (Faith et al., 2004; Gregory, Paxton, & Brozovic, 2010; Lumeng et al., 2012; Webber,
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Cooke, Hill, & Wardle, 2010) or have found an inverse association (Afonso et al., 2016; M. S.
Faith et al., 2004; Jansen et al., 2014; Rodgers et al., 2013; Thompson, Adair, & Bentley, 2013;
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Tschann et al., 2015; Ventura & Birch, 2008). Thinner child weight status has been found in
several studies to predict increases in pressure (Afonso et al., 2016; Jansen et al., 2014;
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Thompson et al., 2013; Tschann et al., 2015; Webber et al., 2010). Several prior studies have
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linked pressuring feeding with picky or restrained eating concurrently (Carper, Orlet Fisher, &
Birch, 2000; Carruth et al., 1998; Farrow et al., 2009; Ventura & Birch, 2008; Wardle, Carnell, &
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Cooke, 2005). We identified only two studies that tested the association between pressuring
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feeding and future picky eating, with conflicting results (Galloway, Fiorito, Lee, & Birch, 2005;
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Gregory et al., 2010) Picky eating has been associated with controlling or pressuring feeding in
in several cross-sectional studies (Clark, Goyder, Bissell, Blank, & Peters, 2007; Faith et al.,
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2004; Galloway et al, 2005; Nowicka, Sorjonen, Pietrobelli, Flodmark, & Faith, 2014; Ventura
& Birch, 2008), but to our knowledge this association has not been tested longitudinally.
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picky eating (Cardona Cano et al., 2015; Dubois, Farmer, Girard, Peterson, & Tatone-Tokuda,
2007; Hafstad, Abebe, Torgersen, & von Soest, 2013; Tharner et al., 2014), pressuring feeding
(Shloim, Edelson, Martin, & Hetherington, 2015), and both over- and under-weight (Ogden,
Lamb, Carroll, & Flegal, 2010) have all been reported to be more common in this demographic.
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Therefore, within a diverse cohort of low-income toddlers followed longitudinally at ages 21, 27,
and 33 months, we sought to test the hypotheses that: (1) pressuring feeding predicts increases
in weight-for-length z-score (WLZ); (2) lower WLZ predicts increases in pressuring feeding; (3)
pressuring feeding predicts increases in picky eating; (4) picky eating predicts increases in
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pressuring feeding; and (5) picky eating predicts decreases in WLZ. To our knowledge, this is
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the first test of these associations including all constructs simultaneously in a longitudinal design.
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SUBJECTS AND METHODS
Participants
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Participants were recruited between 2011 and 2014 via flyers posted in community
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agencies serving low-income families. The study was described as examining whether children
with different levels of stress eat differently. Inclusion criteria were: the biological mother was
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the legal guardian, had an education level less than a 4-year college degree, and was > 18 years
old; the family was English-speaking and was eligible for Head Start, Women, Infants and
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Children (WIC) Program, or Medicaid; and the child was born at a gestational age > 36 weeks,
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developmental delays, and was between 21 and 27 months old. Mothers provided written
informed consent. The University of Michigan Institutional Review Board approved the study.
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Mother-child dyads were invited to participate in three waves of data collection at child
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ages 21, 27, and 33 months. A total of 244 dyads participated, with 186 dyads entering the study
at age 21 months and 58 entering at 27 months to maximize recruitment. This analysis was
limited to those participants with complete data for all measures at a given time point, with 222
participants contributing data at at least one time point. There were 150, 166 and 136 dyads who
participated at the 21, 27, and 33 months, respectively, with 76 dyads participating at all three
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time points. There were 101, 116 and 91 dyads that participated at only two time points (21 and
27, 27 and 33, and 21 and 33 months, respectively). There were no differences between those
who completed the study versus those who did not with regard to child sex, or maternal
depressive symptoms or education. However, those who did not complete the study were more
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likely to be Hispanic or not white than those who remained in the study (94% versus 42%,
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p=0.0002).
Measures
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Mothers reported child sex, age, and race and ethnicity, and maternal education, and
family structure. Child weight and length were measured by trained research staff. Weight-for-
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length was calculated and z-scored based on United States Centers for Disease Control Growth
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Charts. Mothers’ weight and height were measured and body mass index (BMI) calculated.
Pressuring feeding was measured with the Pressuring to Finish subscale of the Infant
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Feeding Styles Questionnaire (IFSQ) (Thompson et al., 2009). Items (Appendix 1) are answered
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on a 1 to 5 scale, with higher scores indicating more pressuring feeding and reverse scoring
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applied as appropriate. Responses to the 8 items are averaged to create a summary score (α =
There is debate in the field regarding the definition of picky eating (Dovey et al., 2008),
and the construct was therefore measured using two approaches. The Children’s Eating
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consists of 6 items (Appendix 1), to which mothers respond on a scale of 1=never to 5=always.
Responses are averaged (α = .87-.90 across age points). The Brief Autism Mealtime Behavior
Inventory (BAMBI) was designed to measure mealtime behavior problems observed in children
with autism, but has strong face validity for the assessment of picky eating behaviors among
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toddlers (Lukens & Linscheid, 2008). Mothers responded on a scale of 1=never to 5=at almost
every meal. We averaged items (Appendix 1) contributing to the original Limited Variety and
Food Refusal subscales to create a Picky Eating Subscale (13 items; α = .75-.78 across age
points).
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Statistical Analysis
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Descriptive analyses were conducted using SAS 9.4 (SAS Institute Inc., Cary, NC).
Univariate statistics were used to describe the sample. One-way repeated measures ANOVAs
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and Chi square were used to test whether WLZ, pressuring feeding, or picky eating differed
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across 21, 27, and 33 months. AN
Path models were conducted (using MPLUS version 7.3; Muthen & Muthen, Los
Angeles, CA) to test the concurrent, longitudinal, and cross-lagged associations between WLZ,
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pressuring feeding, and picky eating at ages 21, 27, and 33 months (Figure 1). This model was
run twice, once using the CEBQ-T Food Fussiness subscale to measure picky eating, and once
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using the BAMBI Picky Eating subscale to measure picky eating. This approach estimates
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tracking of each construct at the individual level measured by the auto-correlation or longitudinal
correlation. Bayesian estimation technique in MPLUS was used to fit models, and Bayesian
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posterior predictive checks (PPC) using Chi-square statistics and the corresponding posterior
predictive p-values (ppp) were used to assess the goodness of fit in each model. A p value within
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0.05 to 0.95 range indicate acceptable fit for the model.(Gelman, 2004)
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Figure 1. Conceptual model for longitudinal associations between WLZ, pressuring feeding,
and picky eating in toddlerhood
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RESULTS
Characteristics of the sample by age point are shown in Table 1. At age 21 months, the
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sample was 50.7% male, 48.0% non-Hispanic white, and 40.0% of mothers had a high school
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education or less. Demographic composition of the cohort did not change significantly across
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age points. WLZ, IFSQ Pressuring to Finish, and BAMBI Picky Eating did not change across
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Child 2.74 .84
Race/Ethnicity
Non-Hispanic 72 (48.0) 78 (47.3) 70 (51.5)
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white
Non-Hispanic 34 (22.8) 43 (26.1) 34 (25.0)
black
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Hispanic (any 15 (10.1) 19 (11.5) 14 (10.3)
race)
Other 28 (18.8) 25 (15.2) 18 (13.2)
Maternal Education 0.24 .89
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<= high school 60 (40.0) 62 (37.4) 53 (39.0)
>High school or 90 (60.0) 104 (62.7) 83 (61.0)
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GED
WLZ 0.52 (1.06) 0.41 (1.08) 0.38 (1.00) 0.87 .42
IFSQ Pressuring to
1.57 (0.56) 1.51 (0.51) 1.56 (0.60) 0.52 .59
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Finish
CEBQ-T Food
2.30 (0.87) 2.46 (0.97) 2.68 (0.96) 6.44 .002
Fussiness
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BAMBI Picky
1.88 (0.55) 1.98 (0.60) 1.98 (0.59) 1.62 .20
Eating
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Cross-lagged analysis results for the conceptual model depicted in Figure 1 are presented
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in Table 2. The fit of both cross-lagged models was good with the ppp value for each model well
within the recommended 0.05 to 0.95 range. Weight-for-length z-score, maternal pressuring
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feeding, and picky eating (by either measure) tracked strongly across all 3 age points. There
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were several concurrent associations between pressuring feeding and picky eating at 21 and 33
months, using both measures of picky eating. There were no prospective associations between
pressuring feeding and future WLZ; WLZ and future pressuring feeding; pressuring feeding
andfuture picky eating; picky eating and future pressuring feeding; or picky eating and future
WLZ.
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Table 2. Path coefficients for model shown in Figure 1 in total sample (n=222)
CEBQ-T Food BAMBI Picky
Path Fussiness Eating
ppp=0.42 ppp=0.22
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WLZ 21m →WLZ 27m b1 0.847* 0.846*
WLZ 27m→ WLZ 33m b2 0.861* 0.856*
Pressuring feeding 21m→ b3 0.677* 0.674*
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Pressuring feeding 27m
Pressuring feeding 27m→ b4 0.547* 0.565*
Pressuring feeding 33m
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Picky eating 21m→ Picky eating 27m b5 0.614* 0.569*
Picky eating 27m→ Picky eating 33m b6 0.743* 0.627*
WLZ 21m→Picky eating 21m b7 -0.124 -0.042
WLZ 27m→ Picky eating 27m b8 0.043 0.064
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WLZ 33 m→ Picky eating 33m b9 -0.048 -0.199
WLZ 21m→Pressuring feeding 21m b10 0.003 0.011
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WLZ 27m→ Pressuring feeding 27m b11 -0.019 -0.032
WLZ 33 mos→ Pressuring feeding 33m b12 -0.082 -0.081
Picky eating 21m→Pressuring feeding 21m b13 0.230* 0.326*
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DISCUSSION
There were several main findings. First, child weight-for-length z-score, maternal self-
report of pressuring her child to eat, and mother-reported child picky eating tracked across
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toddlerhood. Although there was evidence for concurrent associations between maternal report
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of pressuring feeding and maternal report of child picky eating, there was no evidence to support
prospective associations between pressuring feeding and future WLZ; WLZ and future
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pressuring feeding; pressuring feeding and future picky eating; picky eating and future
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Consistent with prior reports, pressuring feeding (Afonso et al., 2016; Faith et al., 2004;
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Gregory et al., 2010; Webber et al., 2010), picky eating (Gregory et al., 2010; Marchi & Cohen,
1990; Mascola, Bryson, & Agras, 2010), and WLZ (Nader et al., 2006) tracked within
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individuals across childhood. We found that mothers who self-reported using pressuring feeding
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practices also rated their children concurrently as pickier eaters, consistent with prior literature
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examining these associations concurrently (Carper et al., 2000; Carruth et al., 1998; Farrow et
al., 2009; Ventura & Birch, 2008; Wardle et al., 2005). These studies used a range of measures
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of pressuring feeding and picky eating, with just one using CEBQ and IFSQ as we did (Farrow et
al., 2009). The cohorts in prior studies were primarily white and middle income and all from the
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US or UK (Carper et al., 2000; Carruth et al., 1998; Farrow et al., 2009; Wardle et al., 2005), in
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contrast to our cohort which was entirely low-income and with greater racial/ethnic diversity.
Prior cohorts had sample sizes similar to ours, ranging from fewer than 200 (Carper et al., 2000;
Carruth et al., 1998; Farrow et al., 2009), to one study with 564 participants (Wardle et al., 2005).
The ages of children in the prior studies were entirely between 2-6 years (Carper et al., 2000;
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Carruth et al., 1998; Farrow et al., 2009), and our cohort was therefore slightly younger. In
summary, among cohorts from the US and UK, who are primarily white and middle-income in
the preschool age range, mothers (and in one case the children themselves (Carper et al., 2000))
report across a range of measures the co-occurrence of maternal pressuring feeding and child
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picky eating. Our findings confirm and extend this observation to a slightly younger age range
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and slightly more racially and ethnically diverse cohort. Future research might consider
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We did not find concurrent associations between pressuring feeding and WLZ. These
findings differ from the primarily inverse associations found in 11 of 13 cross-sectional studies
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among children ages 4 to 12 years in one recent review (Shloim et al., 2015). Our findings may
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have differed from those in this review given that the children in our cohort were younger. In
other studies of toddlers, there have also been null concurrent associations between pressuring
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feeding and child WLZ (Blissett & Farrow, 2007; Lumeng et al., 2012). In addition, as described
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elsewhere (Lumeng et al., 2012), associations between pressuring feeding and WLZ are more
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likely to be null when the measures of pressuring feeding are less controlling or intrusive, as may
have been the case in our study. A different measure of pressuring feeding that captured more
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assertive feeding practices may have found different associations with WLZ.
future growth, consistent with all prior studies that have examined this question (Faith et al.,
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2004; Gregory et al., 2010; Lumeng et al., 2012; Webber et al., 2010). Specifically, a prior study
in a relatively large US cohort that was primarily white and middle-income also found no
prospective association between pressuring feeding at age 15 months and weight gain to 36
months (Lumeng et al., 2012). Among a primarily white cohort of 57 children, there was no
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cross-lagged correlation between pressuring feeding at age 5 years and body mass index at age 7
years (Myles S. Faith et al., 2004). Similarly, among a primarily white cohort of 2- to 4- year old
children in Australia, there was no prospective association between pressuring feeding and body
mass index one year later (Gregory et al., 2010). Likewise, among 7- to 9- year old children in
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the UK, there was no prospective association between pressuring feeding and child body mass
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index 3 years later (Webber et al., 2010). Our study replicates these null prospective findings in
a relatively diverse cohort of low-income US toddlers. Overall, the pattern of results in our study
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as well as prior work suggests that pressuring feeding is unlikely to be a pathway to altering a
child’s growth, particularly for low-income toddlers. Specifically, altering the growth trajectory
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of low-income toddlers (whether to reduce or increase that trajectory) may require other
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strategies besides addressing maternal pressuring feeding.
We also did not find concurrent associations between picky eating and WLZ, consistent
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with the primarily null associations in cross-sectional studies described in a recent review
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(Brown, Schaaf, Cohen, Irby, & Skelton, 2016). We also found no evidence to support the
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hypothesis that picky eating causes either increased or decreased rates of growth, using two
different measures of picky eating, which is also consistent with the primarily null findings of
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Although parents are often cautioned against pressuring their children to eat on the
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premise that pressuring the child could further increase pickiness, we found no evidence to
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support a prospective relationship. This aligns with findings in a primarily white cohort of 156
2- to 4- year old children in Australia; pressuring feeding was not associated with greater food
fussiness one year later when baseline food fussiness was controlled (Gregory et al., 2010). A
prior study among 7 to 9 year old girls found a prospective association between pressuring and
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picky eating 2 years later (Galloway et al., 2005); however, this study did not control for baseline
picky eating, which could explain the discrepancy with other studies. In addition, it is possible
that pressuring feeding prospectively predicts increases in pickiness in school age, but not
toddler and preschool-aged children. Overall, the research to date suggests that pressuring
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feeding in toddler- and preschool-aged children has little impact on changing picky eating, at
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least over a period of one year. Future studies in other age groups and over longer follow up
periods may further clarify any potential association between pressuring feeding and picky
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eating.
Limitations
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There are several limitations to this study. The longitudinal design is a strength, but due
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to the high-risk nature of the study cohort, attrition was high and there were missing data. Results
may not be generalizable to other study populations outside low-income toddlers in the United
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States. There is debate in the field regarding how to best measure the construct of picky eating
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(Brown et al., 2016), and our measures included some variety of reluctance to eat both new foods
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(food neophobia) and familiar foods (picky eating). Despite these limitations, the study was able
to test pathways in common theoretical frameworks in a very young age group longitudinally in
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Conclusion
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We found that maternal pressuring feeding, child picky eating, and weight-for-length z-
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score tracked over a year during early childhood. Although pressuring feeding and picky eating
There are several areas for future work. First, our measure of pressuring feeding has
measures, but compared to some other measures, did not focus as strongly on more intrusive
pressuring feeding strategies (i.e., age inappropriate spoon feeding, bribery, punishment, etc). It
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is possible that findings may differ with alternative definitions of pressuring feeding, and this
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possibility should be explored. Secondly, the findings may differ among different subgroups,
such as children with different weight status at baseline, or from different racial/ethnic or
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socioeconomic groups. Future work should test these associations in different subgroups. Third,
future work should consider examining these associations in even younger age groups, during
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bottle feeding and the transition to solid foods, using longitudinal designs. Finally, additional
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studies that examine pressuring feeding, picky eating, and child growth longitudinally and
employ cross-lagged analyses in large sample sizes with power to detect small but clinically
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In summary, our results call into question the value of attempts to alter maternal
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pressuring feeding as a strategy to alter children’s picky eating or growth. Although parents are
interested in how to reduce picky eating, and providers are enthusiastic about reducing parental
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pressure to eat, there is little evidence that intervening upon these behaviors impacts growth
trajectories. Additional work is needed to identify effective strategies that target salient
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behaviors.
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APPENDIX.
2. It’s important that an infant finish all of the milk in his or her bottle
12. It’s very important that a toddler finish all the food that is on his or her plate
37. I try to get (name of child) to eat even if s/he seems not hungry
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38. If (name of child) will not try a new food that I give him/her, I will work hard to have
him/her try it during that meal
43. I praise (name of child) after each bite to encourage him/her to finish his/her food
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45. I try to get (name of child) to finish his/her food
47. If (name of child) seems full, I encourage him/her to finish his/her food anyway
51. I try to get (name of child) to finish his/her milk
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Food Fussiness Subscale Items from CEBQ-T
8. My child refuses new foods at first.
15. My child enjoys a wide variety of foods REVERSED.
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20. My child enjoys tasting new food REVERSED.
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24. My child is difficult to please with meals.
25. My child decides that s/he doesn’t like food even without tasting it.
29. My child is interested in tasting food s/he hasn’t tasted before REVERSED.
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17. My child prefers only sweet foods (e.g. candy, sugary cereals)
18. My child prefers food prepared in a particular way (e.g. fried foods, cold cereals, raw
vegetables)
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ACKNOWLEDGEMENTS
Author Contributions: JCL, KR, and ALM designed research; JCL, KR and ALM conducted
research; DA and NK analyzed data; JCL wrote the paper; JCL had primary responsibility for
final content. All authors read and approved the final manuscript.
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Conflicts of Interest: The authors have no conflicts of interest to disclose.
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Sources of Support: R01HD069179
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