Posted: September 20th, 2022

key assessment

Key assessment reading logs and powerpoint  

 First, read the provided articles.  You will read two articles per issue, making a total of 12 articles.  For each article, write a reading log summary, reaction, and three questions.   

The reading logs are to be done in a Microsoft office word doc.

There should be a total of 16 slides for the power point not including cover page and reference page.

Key Assessment

Section I: PowerPoint Presentation and 12 Reading Logs

 

Create a
PowerPoint presentation and submit
12 reading logs where you describe and discuss the following key elements of infant development.

Key Elements of Infant Development

1. Infant Feeding – Is it best to breast feed or bottle feed?

2. Infant Feeding – Is it best to feed on a schedule or “on demand?”

3. Infant Sleeping – Is it best for a baby to sleep alone in own room or to co-sleep in same bed with parents?

4. Infant Crying – Is it best to pick baby up when baby cries or to let baby cry it out?  (Infant crying refers to more than just crying at bedtime.  Infant crying refers to any time an infant cry.)

5. Continuity of Care – What is continuity of care and what are the pros and cons?  (The continuity of care term for this course refers to the practice of keeping infants and teachers together for more than one year.)

6. Attachment Theory – What is attachment theory and why is it important?

First, read the provided articles.  You will read two articles per issue, making a total of 12 articles.  For each article, write a reading log summary, reaction, and three questions.  You will submit these twelve reading logs along with your PowerPoint

Next, create a PowerPoint presentation.  Create three slides for each issue, except for issue number 6.  For issue number 6, only one slide is needed.  For issues, 1 – 5, on the first slide, list main points for the first side of the issue (for example, breast feeding).  On the second slide, list main points for the other side of the issue (for example, bottle feeding).  On the third slide state your opinion.   When you create your slides, you should use bullet points for the slides. You should not have more than 6 bullet points per slide and not more than 4 or 5 words after each bullet point.  You may use the notes section of the PowerPoint to provide detailed explanations written in complete sentences.

Finally, create a final slide in your PowerPoint where you discuss how early childhood programs influence an infant’s development and what the short and long term effects of an early childhood program might be on an infant’s development.  Refer to academic articles in this discussion.  Feel free to include pictures or drawings to enhance your discussion.

Summary of Infant responsive feeding article:

In this article the authors use the term responsive feeding to mean feeding on demand.  They suggest that if mothers do not use on demand feeding their babies will become overweight.  The idea is that babies need to learn what it feels like to feel hungry.  When they feel hungry they need to call out to their mothers and have their mothers respond right away by feeding them.  If the mothers listen to their babies’ cues (crying) and feed them, the babies will develop self-regulation and self-control because they will learn that when they have a need the need will be met. They will learn to eat when they are hungry. Babies feel confident and secure when they signal that a need (hunger) needs to be met and then the need is actually met right then and there.  If mothers try to feed their babies when they are not hungry, the babies will learn to eat when someone else thinks they should eat or just because it is a certain time, which could lead to weight problems later in life.  Healthy eating is when a baby eats when she is hungry not when it is a certain time or when someone else thinks she should eat. 

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  • University of Notre Dame

    College of Arts and Letters

    Mother-Baby Behavioral Sleep Laboratory

    Safe Cosleeping Guidelines

    Guidelines to Sleeping Safe with Infants:

    Adapted from: Maximizing the chances of Safe Infant Sleep in the
    Solitary and Cosleeping (Specifically, Bed-sharing) Contexts,

     

    by
    James J. McKenna, Ph.D. Professor of Biological Anthropology, Director,
    Mother-Baby Sleep Laboratory, University of Notre Dame.

    Below is a summary that highlights some of the issues to be concerned
    with as you make your own decisions about where and how your infant
    should sleep.

     What constitutes a “safe sleep environment” irrespective of where the infant sleeps?

    Safe infant sleep ultimately begins with a healthy gestation.
    Specifically, safe infant sleep begins without the fetus being exposed
    to maternal smoke during pregnancy.

    A second factor that has a strong influence on safe infant sleep is
    breastfeeding. Breastfeeding significantly helps to protect infants from
    death including deaths from SIDS/SUDI and from secondary disease and/or
    congenital conditions. Post-natally safe infant sleep begins especially
    with the presence of an informed, breastfeeding, committed mother, or
    an informed and committed father.

    Regardless of whether an infant sleeps on the same surface as his or
    her parents, on a same-surface co-sleeper, in a bassinet or in a
    separate crib, in the same room as their parents or in a separate room,
    all infants should follow these same guidelines: infants
    should always sleep on their backs, on firm surfaces, on clean surfaces,
    in the absence of (secondhand) smoke, under light (comfortable)
    blanketing, and their heads should never be covered. 

    The bed should not have any stuffed animals or pillows around the
    infant and never should an infant be placed to sleep on top of a pillow
    or otherwise soft bedding.

    Sheepskins or other fluffy material and especially beanbag mattresses
    should never be used with infants. Waterbeds can be especially
    dangerous to infants too, and no matter the type of mattress, it should
    always tightly intersect the bed-frame to leave no gaps or space.
    Infants should never sleep on couches or sofas with or without adults as
    they can slip down (face first) into the crevice or get wedged against
    the back of a couch where they may suffocate.

    Bedsharing: It is important to be aware that adult beds were not designed to assure infants safety!

    • It is important to realize that the physical and social
      conditions under which infant-parent cosleeping occur, in all it’s
      diverse forms, can and will determine the risks or benefits of this
      behavior. What goes on in bed is what matters.
    • Bottlefeeding babies should always sleep alongside the mother on a separate surface rather than in the bed.
    • If bedsharing, ideally, both parents should agree and feel
      comfortable with the decision. Each bed-sharer should agree that he or
      she is equally responsible for the infant and acknowledge before
      sleeping that they are aware that the infant is present in the bed
      space. Do not place an infant in the bed with a sleeping adult who is
      not aware that the infant is in the bed with them. My feeling is that
      both parents should think of themselves as primary caregivers.
    • Infants a year or less should not sleep with other/older child
      siblings — but always with a person who can take responsibility for the
      infant being in the bed.
    • Persons taking sedatives, medications or drugs, or intoxicated from
      alcohol or other substances, or otherwise excessively unable to arouse
      easily from sleep should not cosleep on the same surface with the
      infant.
    • Excessively long hair on the mother should be tied up to prevent
      infant entanglement around the infant’s neck (yes, this has very
      unfortunately happened).
    • Extremely obese persons or others who may have difficulty feeling
      where exactly or how close their infant is in relation to their own
      body, may wish to have the infant sleep alongside but on a different
      surface, such as a cosleeper attachment.
    • Finally, it may be important to consider or reflect on whether you
      would think that you suffocated your baby if, under the most unlikely
      scenario, your baby died from SIDS while in your bed. Just as babies can
      die from SIDS in a risk-free solitary sleep environment, it remains
      possible for a baby to die in a risk-free cosleeping/bedsharing
      environment. Just make sure, as much as this is possible, that you would
      not assume that if the baby died, that either you or your spouse would
      think that bed-sharing contributed to the death, or that one of your
      really suffocated (by accident) the infant. While this is an unpleasant
      and uncomfortable topic, it is one that is worth thinking about before
      you make the choice to cosleep/bedshare with your infant.

    Aside from never letting an infant sleep outside the presence
    of a committed adult, i.e. separate-surface cosleeping which is safe
    for all infants, I do not recommend to any parents any particular
    type of sleeping arrangement since I do not know the circumstances
    within which particular parents live. What I do recommend is to consider
    all of the possible choices and to become as informed as is possible
    matching what you learn with what you think can work the best for you
    and your family.

     

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    Mother-Baby Behavioral Sleep Laboratory

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    Schedule or on demand? (Feeding schedules for babies)

    Chatelaine

    , English edition

    68.5

    (May 1995): 36.

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    Like many first-time mothers, I buried myself in baby books. I knew yesterday’s rigid feeding schedules were passe. Happy babies feed on demand, said experts such as Penelope Leach.

    That’s true in the first few months, when a newborn’s small stomach cannot hold much milk or formula (nursing infants need to feed every couple of hours). But by around three or four months, round-the-clock feedings are hard on parents, especially if they have other children, and may not be in the baby’s best interests. Ruth McCamus, a nurse at The Hospital for Sick Children’s Centre for Health Information and Promotion in Toronto, is a great believer in routine. “It helps to plant the idea in the baby’s mind that there is a regularity to the way things happen.”

    Like many first-time mothers, I buried myself in baby books. I knew yesterday’s rigid feeding schedules were passe. Happy babies feed on demand, said experts such as Penelope Leach.
    That’s true in the first few months, when a newborn’s small stomach cannot hold much milk or formula (nursing infants need to feed every couple of hours). But by around three or four months, round-the-clock feedings are hard on parents, especially if they have other children, and may not be in the baby’s best interests. Ruth McCamus, a nurse at The Hospital for Sick Children’s Centre for Health Information and Promotion in Toronto, is a great believer in routine. “It helps to plant the idea in the baby’s mind that there is a regularity to the way things happen.”

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    When my daughter was born nearly two years ago, I was prepared for the worst–feedings every two hours, months of sleepless nights. But I was lucky. From birth, Lucy knew night from day and–with the exception of a brief burst of nursing enthusiasm in the evenings–fed only every three or four hours.

    Like many first-time mothers, I buried myself in baby books. I knew yesterday’s rigid feeding schedules were passe. Happy babies feed on demand, said experts such as Penelope Leach.
    That’s true in the first few months, when a newborn’s small stomach cannot hold much milk or formula (nursing infants need to feed every couple of hours). But by around three or four months, round-the-clock feedings are hard on parents, especially if they have other children, and may not be in the baby’s best interests. Ruth McCamus, a nurse at The Hospital for Sick Children’s Centre for Health Information and Promotion in Toronto, is a great believer in routine. “It helps to plant the idea in the baby’s mind that there is a regularity to the way things happen.”

    Routine tends to become an issue when a mother is returning to work. Day-care workers in particular often cannot cope easily with an infant who expects to feed when the spirit moves him.

    If your baby has not already established a pattern by age four months–that is, you know roughly what to expect from one day to the next–then you’re wise to start encouraging one, McCamus says. But regular doesn’t necessarily mean rigid: the goal is a flexible routine that works for both of you.

    Feeding without fuss

    If your baby feeds well and then cries two hours later, try to postpone the breast or bottle for a while by playing with her or having a cuddle. If she’s a snacker who doesn’t feed long enough to fill up, take a break for 15 or 20 minutes. Then, offer more milk or formula.

    If your baby has day/night confusion, wake him up during the day for regular feedings and playtimes every two to three hours. Keep late-night mealtimes quiet and dimly lit so as not to wake him completely. Eventually, he’ll get the message.

    Don’t wake a sleeping baby in the middle of the night for a feeding unless there is a medical reason to do so, such as insufficient weight gain.

    Don’t be afraid to give a feeding a little earlier than usual if your baby is clearly hungry. Similarly, if she’s content upon waking, immediate feeding may not be necessary.

    Trust your instincts. Too much reliance on parenting books can cause confusion.

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    Copyright Rogers Publishing Limited May 1995

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    Table of contents

    1.

  • How to get a grip on attachment theory
  • ………………………………………………………………………………………….. 1

    07 April 2016 ii ProQuest

    Document 1 of 1

    How to get a grip on attachment theory
    Author: Townshend, Kate
    ProQuest document link
    Abstract: […]I wonder how many of us are really clear about what attachment theory is. “The preliminary
    evidence from our pilot study shows that attachment-based practice in schools can have a positive impact on
    academic performance, reduction in behavioural incidents and improvements in pupil and staff well-being.”
    Full text: Behaviour issues caused by trauma are more common than you may think – but a new project is
    developing strategies to help
    Fresh from teacher training and on the supply circuit, I spent some time in a Reception classroom where I
    discovered that size is no predictor of the severity of behaviour problems. Faced with a tiny boy who spat,
    shouted and, at the age of 5, knew more swear words than I did, I was baffled, panicked and eventually angry.
    Then, at lunchtime, his personal teaching assistant returned from training and my miniature Mr Hyde was
    suddenly transformed into an altogether calmer Dr Jekyll, visibly relaxing after a hug and some soothing words
    from the saintly Mrs M. At the time, I assumed his poor behaviour was entirely down to something I had done
    wrong. But I later learned that this student was suffering from attachment issues.
    Dr Maggie Atkinson, the children’s commissioner for England, believes that “every teacher in every school”
    should be aware of attachment theory and tailor their practice accordingly. But I wonder how many of us do. In
    fact, I wonder how many of us are really clear about what attachment theory is. I certainly wasn’t able to spot
    the signs when they were right in front of me.
    Be aware of the basics
    British psychologist John Bowlby first articulated attachment theory (in the terms we now understand it) in the
    mid-20th century. It is an attempt to explain how the relationship between a child and its parents, particularly the
    mother, influences development.
    Bowlby believed that in the early years of life, a child will form an attachment with a single primary care-giving
    figure and that this relationship will be a prototype for all future relationships. He argued that should an
    attachment fail to form during this period, or be disrupted, then a number of consequences would follow,
    including behaviour problems and reduced ability to learn.
    Teachers should be aware of the implications of this theory. But how prevalent is the problem and how do you
    identify it? The majority of parent-child relationships appear to be strong, after all.
    Fortunately, identifying children with attachment issues is possible. Schools may already be aware of
    circumstances that could affect attachment. If not, resilience is often a key factor: a child who gives up at the
    first sign of failure may be lacking the secure base required to try again.
    And more children may be suffering from these issues than you expect. A key study on attachment, conducted
    by Christi and David Bergin in 2009, estimates that up to a third of all children have an insecure attachment to at
    least one caregiver. A 2004 study from Scotland, meanwhile, posits that almost all children will have
    experienced trauma of some kind by the end of their primary years.
    But just being aware of attachment theory is not enough: teachers need to use it to inform how they teach and
    form relationships with students.
    So where to begin? The Attachment Aware Schools project brings together university-based researchers and
    local practitioners in Somerset to provide training on bringing ideas about attachment into classrooms (for more
    information, visit www.attachmentawareschools.com).
    In 2013 and 2014, the project’s organisers ran a pilot study in 11 schools and colleges, with each committing to
    a programme of training in areas such as trauma and its implications for learning. Each institution devised its

    07 April 2016 Page 1 of 4 ProQuest

    http://nclive.org/cgi-bin/nclsm?url=http://search.proquest.com/docview/1625312946?accountid=11330

    own whole-school approaches to being “attachment aware” with the help of a consultant.
    The initial results were excellent, with all participants reporting that they had found the process useful and that it
    had had a big impact on learning.
    Dr Janet Rose of Bath Spa University is part of the research group leading the programme. She explains:
    “Attachment theory is already well recognised in areas such as clinical psychology, health and social care.
    “The preliminary evidence from our pilot study shows that attachment-based practice in schools can have a
    positive impact on academic performance, reduction in behavioural incidents and improvements in pupil and
    staff well-being.”
    Putting theory into practice
    So far, so good. But what does attachment theory look like in practice? And what new strategies are emerging?
    One example is the use of “emotion coaching”. Originating in the US and historically used in helping parents to
    relate to their children, it involves recognising, naming and validating the feelings and emotions that may cause
    disruptive behaviour rather than dismissing them.
    In particular, there is an emphasis on changing the language used to deal with poor behaviour, enabling
    children to understand and manage their feelings more successfully.
    For example, parents would be advised to say: “I’m sorry you’re feeling so angry and I’d like to talk to you more
    about it, but I still need you to stop throwing things” (instead of: “It’s very silly to throw things so stop it right
    now!”). It is a strategy that has been embraced by many of the pilot schools in the Attachment Aware scheme,
    and Ed Harker, headteacher of St Saviours CEVC Nursery and Infant School in Bath, has already seen positive
    results.
    “We have found that children with attachment disorders have responded really well,” he explains. “And on a
    practical level, attachment theory has changed the specific language we use with all the children.”
    The Attachment Aware project and its pilot schools offer further specific ways of bringing attachment into an
    educational setting, from appointing an attachment leader to using nurture groups to help children process their
    feelings better.
    Harker says that the interventions at St Saviours – such as a “nurture” space for children to use at lunchtime –
    have had a school-wide impact.
    “There is a better emotional intelligence within the school team now and a raised awareness of attachment
    needs,” he says. “It gives you the understanding you need to adapt your provision and ensure that potentially
    vulnerable children are helped to thrive.”
    Fighting the fear
    But it is not just about interventions, according to Dr Rose. What can also be effective in schools, she believes,
    is the modelling of attachment. “Most teachers are likely to encounter insecurely attached and traumatised
    children in their classrooms,” she says. “A warm, supportive teacher can actually promote attachment
    relationships.”
    Roger Catchpole, a consultant for children’s mental health charity YoungMinds, agrees: “There is strong
    evidence for the protective power of one important adult in a child’s life who can provide them with unconditional
    positive regard. This is often found in school.” He points out that this does not have to be a teacher and could
    equally be a teaching assistant or other member of support staff.
    The Attachment Aware project also recommends assigning “key adults” to needy children. These are trained
    adults within the school who take a particular interest in a child, supporting their emotional development and
    reducing their anxiety. And although “unconditional positive regard” may seem to suggest overlooking or
    indulging poor behaviour, it is more about giving children a sense that they are liked and cared for in spite of
    their behaviour.
    This may make some teachers feel uncomfortable, particularly considering that adults are often advised to keep
    a careful distance from students for child protection and authority. But as Harker says, if attachments are

    07 April 2016 Page 2 of 4 ProQuest

    “appropriate” and “secure” there is nothing to fear.
    Fear is perhaps as important a factor as ignorance in stopping attachment theory being more widely
    implemented in schools. We have become so guarded when it comes to children and so concerned with data
    that we can forget about the importance of relationships in teaching. For those children lucky enough to get a
    great start in life, this is damaging. But for those with attachment issues it can be nothing short of destructive.
    Kate Townshend is a teacher at a primary school in Gloucestershire
    What else?
    Create an attachment-based nurture group with these detailed resources.
    bit.ly/NurtureGroup
    Use this mind map to identify the many issues faced by students with attachment disorders.
    bit.ly/AttachmentDisorder
    References
    Bergin, C and Bergin, D (2009) “Attachment in the classroom”, Educational Psychology Review, 21: 141-70.
    O’Connor, M and Russell, A (2004) “Identifying the incidence of psychological trauma and post-trauma
    symptoms in children, A Survey of Three Clackmannanshire Schools”, Clackmannanshire Council
    Psychological Service.
    Subject: Children & youth; Students; Theory; Learning;
    Publication title: The Times Educational Supplement
    Issue: 5120
    Publication year: 2014
    Publication date: Nov 7, 2014
    Year: 2014
    Section: News
    Publisher: TES Global Limited
    Place of publication: London
    Country of publication: United Kingdom
    Publication subject: Education
    ISSN: 00407887
    Source type: Trade Journals
    Language of publication: English
    Document type: News
    ProQuest document ID: 1625312946
    Document URL: http://nclive.org/cgi-
    bin/nclsm?url=http://search.proquest.com/docview/1625312946?accountid=11330
    Copyright: Copyright TSL Education Ltd. Nov 7, 2014
    Last updated: 2014-11-17
    Database: ProQuest Central

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      How to get a grip on attachment theory

    Clearinghouse on Elementary and
    Early Childhood Education

    University of Illinois • 51 Gerty Drive • Champaign, IL 61820-7469 ERIC DIGEST
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  • Continuity of Caregiver
  • for Infants and Toddlers
    Debby Cryer, Sarah Hurwitz, and Mark Wolery

    According to the 1999 National Survey of American
    Families, an estimated 10% of infants under a year of age
    are participating in center-based care and education
    programs, while the numbers are higher for 1-year-olds
    (16%) and 2-year-olds (24%) (Ehrle, Adams, & Tout,
    2001). The practices used in caring for these infants and
    toddlers may have strong and enduring impacts on
    children’s development and well-being. In terms of child
    care quality during the first three years, higher quality is
    associated with better mother-child relationships, fewer
    reports of children’s behavior problems, higher cognitive
    and language outcomes, and better readiness for school
    (Burchinal et al., 1996; NICHD Early Child Care Research
    Network, 1996). In addition to the general quality of care
    for infants and toddlers, discrete practices may influence
    the development of infants and toddlers. One practice that
    is currently attracting substantial interest is the provision of
    continuity of caregivers for young children. Continuity of
    caregivers means that infants and toddlers remain with
    the same teacher(s) during a significant part, if not all, of
    their first years in a program.
    Continuity of Caregiver
    Traditionally, young children in center-based child care
    programs have a series of different caregivers during the
    first three years of life. Centers often follow the lock-step
    elementary school practice of moving children to a
    different class/teacher at the end of the year. Many
    programs move children more often, from class to class,
    teacher to teacher, as soon as they attain certain
    developmental milestones, such as crawling or walking.
    Some programs may move children on a daily basis to
    meet ratio or other staffing requirements. This practice is
    often used to ensure efficient use of program resources
    by keeping classes full and enrolling infants, for whom
    there is more child care demand. High rates of teacher
    turnover increase the likelihood that children will change
    teachers repeatedly during the infant/toddler years
    (Helburn, 1995; Whitebook, Howes, & Phillips, 1989).
    The rationale for continuity of caregiver is similar to that for
    assigning primary caregivers to very young children.
    Primary caregivers take major responsibility for meeting
    the care and educational needs of a small group of children,
    within a larger group. Both practices, continuity of caregiver
    and primary caregiver, are intended to create a consistent
    personal relationship between a child and a teacher.
    In these practices (primary caregiver and continuity of
    caregiver), transitions between teachers are minimized
    because transitions are seen as being stressful for the
    child (and adults) and wasteful in terms of learning time.
    When a child is moved to a new caregiver, recommended
    practice suggests that strategies be used to ease transi-
    tions. For example, children can visit their new class and

    teacher before moving, or their new teacher can visit them
    a few times so that they can get to know one another.
    Theory and Research
    The current professional recommendation of continuity of
    caregiver for infants and toddlers is based on conclusions
    drawn from child development theory and from limited
    research findings. Theoretically, issues regarding the
    development of secure maternal attachment are
    considered paramount for infants and toddlers (Ainsworth
    et al., 1978; Bowlby, 1982; Smith & Pederson, 1988).
    Secure maternal relationships are associated with more
    positive child outcomes, especially with regard to social-
    emotional development (e.g., Matas, Arend, & Sroufe,
    1978; Jacobson & Wille, 1986). There also is evidence
    that maternal attachment is related to children’s language
    development (Klann-Delius & Hofmeister, 1997; van
    Ijzendoorn et al., 1995), cognitive development (van
    Ijzendoorn et al., 1995), and emergent literacy (Bus & van
    Ijzendoorn, 1988).
    Some evidence suggests that in addition to attachment to
    mothers, the child’s attachment to a primary caregiver in
    out-of-home child care is also important (Cummings,
    1980; Goossens & van Ijzendoorn, 1990; Howes &
    Hamilton, 1992). Raikes’ (1993) research suggests that
    children take a significant amount of time to form
    attachments to caregivers, so they are less likely to form
    attachments if frequent caregiver changes occur. Howes
    and Hamilton (1992) found that with multiple changes in
    caregivers, toddlers are less likely to relate to a new
    caregiver based on her own behavior but rather re-create
    the quality of the relationship with a previous caregiver.
    They also report a relationship between the number of
    caregiver losses experienced by a preschooler and the
    likelihood that the child will be socially withdrawn or
    aggressive with peers (Howes & Hamilton, 1993). It is
    possible that the effects of caregiver changes might relate
    to other areas of children’s development as well.
    Current Practice
    The extent to which children change caregivers during the
    first three years in child care centers is not known, but it is
    assumed to be high (Howes & Hamilton, 1993). Likewise,
    little is known about the extent to which continuity of
    caregiver is practiced, although reports of survey research
    conducted by Cryer et al. (2000) of 273 centers indicate
    that relatively few programs, whether accredited or non-
    accredited, provide continuity of caregivers for infants and
    even fewer provide it for toddlers.
    Implementing Continuity of Caregiver
    When the practice of continuity of caregiver is
    implemented in child care centers, various strategies are

    used. For example, the amount of time that children
    remain with the same teacher might vary, with some
    having the same teacher through the first and second
    years, and others having the same teacher for a shorter
    but extended period (e.g., 18 months). Keeping children
    with the same teacher is more likely when multiage
    groups are used, because having a birthday or reaching
    developmental milestones does not force a change in
    class. Continuity of caregiver, however, is also used with
    same-age groupings. Teachers and their children may
    use the same physical space through their years together,
    or they may move from one classroom to another. In
    classes with multiple teachers, all teachers and children
    might move together, while in another setting, a subgroup
    of children might move with only one of the teachers.
    Thus, even within this practice (continuity of caregivers),
    there can be substantial variation. Yet the major
    requirement for providing continuity of caregiver is met.
    To offer continuity of care for infants and toddlers, center
    staff might want to consider the following suggestions:
    • Avoid taking new children only in the youngest group;

    this practice forces moving children up one at a time
    and separates them from the teacher to whom they
    are attached.

    • Recruit new children to fill in at upper age levels when
    it is more appropriate to have more children per adult.

    • Use mixed-age groupings.
    • Reward staff for longevity with the program.
    • If a staff member leaves, overlap staff so that children

    are never left with strangers.
    Conclusion
    Although positive child development effects may be
    associated with the practice of continuity of caregiver, it is
    certainly possible that there are also negative effects
    associated with the practice. For example, if a child
    spends several years with a teacher who interacts
    negatively with the child, undesirable outcomes would be
    likely. At this time, the actual effects associated with the
    practice are based only on theoretical assumption and
    limited research. Center staff may require more
    compelling evidence that a practice is truly a better option
    before undertaking the substantial modifications that are
    required in making a significant change.
    For More Information
    Ainsworth, M., Blehar, M., Waters, E., & Wall, S. (1978).
    Patterns of attachment: A psychological study of the Strange
    Situation. Hillsdale, NJ: Erlbaum.
    Bowlby, J. (1982). Attachment and loss. Vol. 1: Attachment.
    New York: Basic.
    Burchinal, M., Roberts, J., Nabors, L., & Bryant, D. (1996).
    Quality of center child care and infant cognitive and
    language development. Child Development, 67(2), 606-620.
    EJ 523 402.
    Bus, A. G., & van Ijzendoorn, M. H. (1988). Mother-child
    interactions, attachment and emergent literacy: A cross-
    sectional study. Child Development, 59(5), 1262-1272. EJ
    380 597.
    Cryer, D., Hurwitz, S., & Wolery, M. (2000). Continuity of
    caregiver for infants and toddlers in center-based child care:
    Report on a survey of center practices. Early Childhood
    Research Quarterly, 15(4), 497-514. EJ 635 662.
    Cummings, E. M. (1980). Caregiver stability and day care.
    Developmental Psychology, 16(1), 31-37.

    Ehrle, J., Adams, G., & Tout, K. (2001). Who’s caring for our
    youngest children? Child care patterns of infants and
    toddlers. Washington, DC: Urban Institute. ED 448 908.
    Essa, E. L., Favre, K., Thweatt, G., & Waugh, S. (1999).
    Continuity of care for infants and toddlers. Early
    Development and Care, 148, 11-19.
    Goossens, F. A., & van Ijzendoorn, M. H. (1990). Quality of
    infants’ attachments to professional caregivers: Relation to
    infant-parent and day-care characteristics. Child Develop-
    ment, 61(3), 832-837. EJ 413 810.
    Helburn, S. W. (Ed.). (1995). Cost, quality, and child
    outcomes in child care centers. Technical report. Denver:
    University of Colorado at Denver. ED 386 297.
    Howes, C., & Hamilton, C. E. (1992). Children’s relationships
    with caregivers: Mothers and child care teachers. Child
    Development, 63(4), 859-866. EJ 450 556.
    Howes, C., & Hamilton, C. E. (1993). The changing
    experience of child care: Changes in teachers and in
    teacher-child relationships and children’s social competence
    with peers. Early Childhood Research Quarterly, 8(1), 15-32.
    EJ 461 737.
    Jacobson, J. L., & Wille, D. E. (1986). The influence of
    attachment pattern on developmental changes in peer
    interaction from the toddler to the preschool period. Child
    Development, 57(2), 338-347. EJ 357 931.
    Klann-Delius, G., & Hofmeister, C. (1997). The development
    of communicative competence of securely and insecurely
    attached children in interactions with their mothers. Journal
    of Psycholinguistic Research, 26(1), 69-88.
    Matas, L., Arend, R., & Sroufe, L. (1978). Continuity of
    adaptation in the second year: The relationship between
    quality of attachment and later competence. Child Develop-
    ment, 49(3), 547-556. EJ 190 989.
    NICHD Early Child Care Research Network. (1996).
    Characteristics of infant child care: Factors contributing to
    positive caregiving. Early Childhood Research Quarterly,
    11(3), 269-306. EJ 534 662.
    Raikes, H. (1993). Relationship duration in infant care: Time
    with a high-ability teacher and infant-teacher attachment. Early
    Childhood Research Quarterly, 8(3), 309-325. EJ 474 787.
    Smith, P. B., & Pederson, D. R. (1988). Maternal sensitivity
    and patterns of infant-mother attachment. Child Develop-
    ment, 59(4), 1097-1101. EJ 377 898.
    van Ijzendoorn, M. H., Dijkstra, J., & Bus, A. G. (1995).
    Attachment, intelligence and language: A meta-analysis.
    Social Development, 4(2), 115-128.
    Whitebook, M., Howes, C., & Phillips, D. (1989). Who cares?
    Child care teachers and the quality of care in America. Final
    report of the National Child Care Staffing Study. Oakland,
    CA: Child Care Employee Project.
    ____________________
    References identified with an ED (ERIC document), EJ (ERIC journal), or PS
    number are cited in the ERIC database. Most documents are available in ERIC
    microfiche collections at more than 1,000 locations worldwide (see
    http://www.ed.gov/Programs/EROD/). They can also be ordered through EDRS:
    800-443-ERIC or online at http://www.edrs.com/Express.cfm. Journal articles are
    available from the original journal, interlibrary loan services, or article reproduction
    clearinghouses such as Ingenta (800-296-2221).

    ERIC Digests are in the public domain and may be freely reproduced.
    This project has been funded at least in part with Federal funds from the U.S.
    Department of Education, under contract number ED-99-CO-0020. The content
    of this publication does not necessarily reflect the views or policies of the U.S.
    Department of Education, nor does mention of trade names, commercial
    products, or organizations imply endorsement by the U.S. Government.

      Continuity of Caregiver

    Infant Feeding and Childhood Cognition at Ages 3 and 7 Years
    Effects of Breastfeeding Duration and Exclusivity
    Mandy B. Belfort, MD, MPH; Sheryl L. Rifas-Shiman, MPH; Ken P. Kleinman, ScD; Lauren B. Guthrie, MPH;
    David C. Bellinger, PhD; Elsie M. Taveras, MD, MPH; Matthew W. Gillman, MD, SM; Emily Oken, MD, MPH

    IMPORTANCE Breastfeeding may benefit child cognitive development, but few studies have
    quantified breastfeeding duration or exclusivity, nor has any study to date examined the role
    of maternal diet during lactation on child cognition.

    OBJECTIVES To examine relationships of breastfeeding duration and exclusivity with child
    cognition at ages 3 and 7 years and to evaluate the extent to which maternal fish intake
    during lactation modifies associations of infant feeding with later cognition.

    DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study (Project Viva), a US prebirth
    cohort that enrolled mothers from April 22, 1999, to July 31, 2002, and followed up children
    to age 7 years, including 1312 Project Viva mothers and children.

    MAIN EXPOSURE Duration of any breastfeeding to age 12 months.

    MAIN OUTCOMES AND MEASURES Child receptive language assessed with the Peabody
    Picture Vocabulary Test at age 3 years, Wide Range Assessment of Visual Motor Abilities at
    ages 3 and 7 years, and Kaufman Brief Intelligence Test and Wide Range Assessment of
    Memory and Learning at age 7 years.

    RESULTS Adjusting for sociodemographics, maternal intelligence, and home environment in
    linear regression, longer breastfeeding duration was associated with higher Peabody Picture
    Vocabulary Test score at age 3 years (0.21; 95% CI, 0.03-0.38 points per month breastfed)
    and with higher intelligence on the Kaufman Brief Intelligence Test at age 7 years (0.35;
    0.16-0.53 verbal points per month breastfed; and 0.29; 0.05-0.54 nonverbal points per
    month breastfed). Breastfeeding duration was not associated with Wide Range Assessment
    of Memory and Learning scores. Beneficial effects of breastfeeding on the Wide Range
    Assessment of Visual Motor Abilities at age 3 years seemed greater for women who
    consumed 2 or more servings of fish per week (0.24; 0.00-0.47 points per month breastfed)
    compared with less than 2 servings of fish per week (−0.01; −0.22 to 0.20 points per month
    breastfed) (P = .16 for interaction).

    CONCLUSIONS AND RELEVANCE Our results support a causal relationship of breastfeeding
    duration with receptive language and verbal and nonverbal intelligence later in life.

    JAMA Pediatr. 2013;167(9):836-844. doi:10.1001/jamapediatrics.2013.45

    5

    Published online July 29, 2013.

    Editorial page 79

    6

    Author Affiliations: Division of
    Newborn Medicine, Boston Children’s
    Hospital, Harvard Medical School,
    Boston, Massachusetts (Belfort);
    Department of Population Medicine,
    Harvard Medical School and Harvard
    Pilgrim Health Care Institute, Boston,
    Massachusetts (Rifas-Shiman,
    Kleinman, Guthrie, Taveras, Gillman,
    Oken); Department of Neurology,
    Boston Children’s Hospital, Harvard
    Medical School, Boston,
    Massachusetts (Bellinger);
    Departments of Epidemiology and
    Nutrition, Harvard School of Public
    Health, Boston, Massachusetts
    (Gillman).

    Corresponding Author: Mandy B.
    Belfort, MD, MPH, Division of
    Newborn Medicine, Boston Children’s
    Hospital, Harvard Medical School,
    Hunnewell Room 438, 30

    0

    Longwood Ave, Boston, MA 02115
    (mandy.belfort@childrens.harvard
    .edu).

    Research

    Original Investigation

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    S trong evidence supports the relationship between breast-
    feeding and health benefits in infancy, including pre-
    vention of gastrointestinal tract infections and otitis

    media.1 The extent to which breastfeeding leads to better cog-
    nitive development is less certain. While observational
    studies1-4 have reported positive associations of breastfeed-
    ing with later intelligence, breastfeeding is strongly related to
    determinants of child intelligence, such as maternal intelli-
    gence, and developmental stimulation received by the child;
    residual confounding by such shared determinants may have
    led observational studies1,2,5 to overestimate the effect of
    breastfeeding on child intelligence. Another limitation of prior
    investigations is the classification of infant feeding as ever
    vs never breastfed.4 Failure to account for partial vs exclu-
    sive breastfeeding or breastfeeding duration could lead to
    underestimation of the true effect of breastfeeding on child
    intelligence. Detailed data regarding breastfeeding exposure
    and adequate control for confounding factors are necessary
    for valid estimates of the relationship between breastfeed-
    ing and later intelligence, but no study to date has fulfilled
    these requirements.

    Nutrients in breast milk, such as n-3 fatty acid docosa-
    hexaenoic acid (DHA), may benefit the developing brain.
    A major determinant of breast milk DHA content is
    the mother’s diet,6 and fish is a rich source of DHA. In
    pregnancy, greater maternal fish intake (particularly fish
    low in mercury contamination) is associated with better
    childhood cognitive outcomes,7 but the extent to which
    maternal fish intake during lactation accounts for the
    relationship between breastfeeding and cognition has not
    been reported. The aims of our study were 2-fold: (1) to
    examine relationships of breastfeeding duration and ex-
    clusivity with child cognition at ages 3 and 7 years and (2) to
    evaluate the extent to which maternal fish intake during
    lactation modifies associations of infant feeding with later
    cognition.

    Methods
    Participants
    We studied participants in Project Viva, a prospective, longi-
    tudinal cohort study designed to examine prenatal factors
    in relation to pregnancy and child health. From April 22,
    1999, to July 31, 2002, Project Viva enrolled pregnant
    women attending prenatal care at 8 obstetrical offices of a
    multispecialty group practice in eastern Massachusetts.
    Exclusion criteria included multiple gestation, inability to
    answer questions in English, gestational age of at least 2

    2

    weeks at the initial prenatal care appointment, and plans to
    move away from the area before delivery. Recruitment and
    follow-up details at birth,8 at 6 months,9 and at 3 years10

    have been reported. Follow-up data collection at age 7 years
    was completed in December 2010. Human investigation
    committees of the Harvard Pilgrim Health Care Institute,
    Brigham and Women’s Hospital, and Beth Israel Deaconess
    Medical Center approved the study, and mothers of all par-
    ticipating children gave written informed consent.

    Of 2128 women who delivered a live infant, we excluded
    45 children born at a gestational age of less than 34 weeks, 325
    children who were missing breastfeeding status at age 6 months
    and breastfeeding duration at age 12 months, and 446 chil-
    dren who were missing cognitive measures at ages 3 and 7 years.
    Therefore, our sample for this analysis comprised 1312 Proj-
    ect Viva mothers and children (1224 at age 3 years and 1037 at
    age 7 years).

    Measurements
    Breastfeeding
    When the participating child was ages 6 and 12 months, we
    asked the mother the questions listed in Table 1. To deter-
    mine breastfeeding exclusivity at ages 6 and 12 months, we
    asked detailed questions about the age at which solid foods
    and non–breast milk liquids were introduced.

    Cognition
    When children were age 3 years, trained research staff
    administered the Peabody Picture Vocabulary Test–Third
    Edition (PPVT-III),11 a test of receptive language correlated
    (Pearson R = 0.90) with intelligence tests, such as the
    Wechsler Intelligence Scale for Children III. We also admin-
    istered the Wide Range Assessment of Visual Motor Abilities
    (WRAVMA)12 pegboard (fine motor), matching (visual spa-
    tial), and drawing (visual motor) subtests. Subtest scores are
    reported individually and combined as a visual motor com-
    posite score.

    At age 7 years, we administered the WRAVMA drawing sub-
    test and the Kaufman Brief Intelligence Test–Second Edition
    (KBIT-II), which measures verbal and nonverbal intelligen

    ce

    and is correlated (Pearson R = 0.89) with the Wechsler Intel-
    ligence Scale for Children III.13 In addition, we assessed memory
    and learning with the Wide Range Assessment of Memory and
    Learning (WRAML)14 design memory and picture memory
    tests. Scores were summed to yield a visual memory com-
    bined score.

    Table 1. Questions About Breastfeeding at Ages 6 and 12 Months

    Question About Breastfeeding
    At Age 6 mo

    For all infants

    (1) Have you ever breastfed your baby? By breastfeeding, we mean that
    you have put your baby to your breast, whether or not your baby actually
    received breast milk, or that you have fed your baby your breast milk.
    (2) Are you now feeding your baby any infant formula?

    (3) Are you now feeding your baby any breast milk?

    For weaned infants

    How old was your baby when you stopped breastfeeding?

    At Age 12 mo

    For all infants

    Have you ever breastfed your child?

    Are you still breastfeeding at all?

    For weaned infants

    How old was your child when you stopped breastfeeding?

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    Study staff administering cognitive tests were unaware of
    the children’s breastfeeding status. The PPVT-III, WRAVMA,
    and KBIT-II are scaled to a mean (SD) score of 100 (15).

    Covariates
    We collected data from mothers regarding parental and child
    demographic, social, economic, and health information
    through self-administered questionnaires and interviews in
    pregnancy and shortly after delivery.15 At 6 months’ post par-
    tum, we administered a brief, validated food frequency
    questionnaire,16 including questions about the mother’s mean
    weekly fish intake (canned tuna fish, shellfish, and dark meat
    fish [eg, mackerel, salmon, sardines, bluefish, or swordfish],
    as well as other fish [eg, cod, haddock, or halibut]) since the
    infant’s birth. To measure maternal intelligence, we adminis-
    tered to mothers the PPVT-III when the child was age 3 years
    and the KBIT-II when the child was age 7 years. We also ad-
    ministered the Home Observation Measurement of the Envi-
    ronment short form (HOME-SF),17 which measures cognitive
    stimulation and emotional support in the child’s environ-
    ment. Higher scores (range, 0-22) indicate more favorable en-
    vironments.

    Data Analysis
    Our main exposures were the following: (1) duration of any
    breastfeeding in months; (2) duration of exclusive breastfeed-
    ing in months, defined as feeding breast milk but no solid foods
    or non–breast milk liquids (except water) to age 6 months; and
    (3) breastfeeding status at age 6 months, categorized as “for-
    mula only, never breast fed,” “formula only, weaned,” “mixed
    formula and breast milk,” and “breast milk only, no formula.”
    Our outcome measures were the PPVT-III and WRAVMA scores
    at age 3 years and the KBIT-II, WRAVMA, and WRAML scores
    at age 7 years. To examine the effect of potential confounders
    on estimated relationships of breastfeeding measures with cog-
    nitive outcome measures, we adjusted for 4 models in linear
    regression. Model 0 adjusted for child age and sex. Model 1 ad-
    justed for covariates in model 0 plus gestational age and birth
    weight z score.18 Model 2 adjusted for covariates in model 1 plus
    child race/ethnicity and maternal age, parity, smoking status,
    depression at 6 months’ post partum, and employment and
    child care at age 6 months, as well as primary language, an-
    nual household income, and parental educational level and
    marital status. Model 3 adjusted for covariates in model 2 plus
    HOME-SF score. Model 4 adjusted for covariates in model 3 plus
    maternal PPVT-III or KBIT-II score.

    To compare our results with those of other studies, we es-
    timated the difference in cognitive test scores between chil-
    dren ever vs never breastfed. To examine the extent to which
    maternal fish intake modified relationships of breastfeeding
    with outcome measures, we stratified by fish intake (<2 vs ≥2 servings per week) and calculated the P value for an interac- tion term (breastfeeding duration × fish intake) in linear re- gression.

    All covariates were not observed in all participants. Using
    only individuals with all data observed would have resulted
    in a smaller sample size, with most excluded participants miss-
    ing only 1 or 2 values, leading to lost information and possibly

    a selected subset. Therefore, we used multiple imputation to
    generate several plausible values for each missing value.19 To
    generate imputation data sets, we used a set of variables cho-
    sen from the thousands available in Project Viva to reflect
    demographic and other factors that we deemed plausibly re-
    lated to potential missingness mechanisms and to the expo-
    sures and outcome measures. A “completed” data set in-
    cludes the observed data and an imputed value for each missing
    value. The analysis was replicated across completed data sets
    and then combined in a structured fashion that accurately re-
    flects the true amount of information in the observed data.
    This method assumes that the exposures and outcome mea-
    sures are missing completely at random given the observed
    variables and the imputed covariates. This is a reduced as-
    sumption relative to that made in studies that use only com-
    plete cases. Using a statistical program (Proc MI ANALYZE in
    SAS, version 9.3; SAS Institute, Inc), we generated 50 complete
    data sets and combined multivariable modeling results for all
    2128 participants in the Project Viva cohort. For this analysis,
    we excluded participants born at a gestational age of less than
    34 weeks and those missing observed exposure or outcome
    data.

    Results
    Table 2 summarizes characteristics of participants included at
    ages 3 and 7 years and characteristics of the excluded partici-
    pants. Compared with those included in the analysis, moth-
    ers of excluded participants were less educated, had lower an-
    nual household income, were more likely to be of nonwhite
    race/ethnicity, and breastfed for a shorter duration. For 122

    4

    participants included at age 3 years, the mean duration of any
    breastfeeding was 6.4 months and of exclusive breastfeeding
    was 2.4 months; values were similar for participants in-
    cluded at age 7 years. The PPVT-III mean score at age 3 years
    was 103.7, and the KBIT-II verbal mean score at age 7 years was
    112.5.

    Table 3 summarizes the effect of covariate adjustment on
    estimated relationships between breastfeeding duration and
    child cognitive outcomes. Adjusting for child age and sex
    (model 0), longer breastfeeding duration was associated with
    higher PPVT-III score at age 3 years (0.58; 95% CI, 0.40-0.76
    points per month breastfed). This relationship was similar with
    additional adjustment for fetal growth and gestational age
    (model 1) and attenuated with adjustment for demographic
    variables (model 2) and HOME-SF score (model 3). With fur-
    ther adjustment for maternal IQ (model 4), the association di-
    minished to 0.21 (95% CI, 0.03-0.38) points per month breast-
    fed. We observed a similar pattern of attenuation for the KBIT-II
    verbal and nonverbal scores at age 7 years.

    In Table 4, we give fully adjusted associations of any and
    exclusive breastfeeding with all cognitive test scores at ages

    3

    and 7 years. Associations of breastfeeding duration (any and
    exclusive) with the PPVT-III score and the KBIT-II verbal and
    nonverbal scores were positive, and 95% CIs excluded 0. The
    Figure shows the adjusted KBIT-II scores at age 7 years by cat-
    egory of any breastfeeding duration (<1, 1-3, 4-6, 7-9, 10-11, and

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    Table 2. Included and Excluded Project Viva Mothers and Children

    Variable

    Included at Age 3
    y

    (n = 1224)
    Included at Age 7 y

    (n = 1037)
    Excluded at Ages 3 and 7 ya

    (n = 771)

    Mother

    Age, mean (SE), y 32.5 (0.1) 32.3 (0.2) 31.0 (0.2)

    PPVT-III score, mean (SE) 106.0 (0.4) 105.4 (0.5) 100.8 (0.8)

    KBIT-II score, mean (SE) 107.9 (0.5) 107.2 (0.5) 102.5 (0.7)

    ≥2 Servings of fish per wk, % 55.0 52.8 50.

    1

    Parity, %

    0 47.5 47.3 47.6

    1 36.3 36.4 35.4

    ≥2 16.2 16.4 17.0

    Smoking status, %

    Never 68.8 70.1 64.5

    Former 21.0 20.1 17.4

    During pregnancy 10.2 9.8 18.1

    Depression at 6 mo post partum, % 8.8 9.1 11.0

    Educational level, %

    ≤High school diploma 7.2 8.6 18.8

    Some college 20.2 21.3 26.9

    Bachelor’s degree 37.7 34.9 32.7

    Graduate degree 34.9 35.2 21.6

    Employment at 6 mo post partum, %

    Employed 66.0 66.7 56.0

    Employed, on maternity leave 6.0 6.8 6.2

    Not employed, looking 4.6 5.3 10.1

    Not employed, not looking 23.3 21.3 27.7

    Child

    Gestational age, mean (SE), wk 39.6 (0.0) 39.7 (0.0) 39.6 (0.1)

    Birth weight, mean (SE), kg 3.5 (0.0) 3.5 (0.0) 3.5 (0.0)

    Birth weight for gestational age z
    score, mean (SE)

    0.22 (0.03) 0.20 (0.00) 0.14 (0.04)

    Female sex, % 50.4 50.5 47.7

    Race/ethnicity, %

    Asian 2.7 3.0 5.8

    Black 11.9 15.1 21.0

    Hispanic 3.5 3.7 8.0

    White 70.1 66.1 55.4

    Other 11.8 12.2 9.8

    Primary English speaker, % 96.2 98.7 92.7

    Child care at age 6 mo, %

    Center 16.8 17.2 17.4

    Other home 26.1 27.3 24.8

    At own home 14.3 13.6 14.9

    None 42.8 42.0 43.0

    Breastfeeding status at age 6 mo, %

    Formula only, never breastfed 10.6 10.1 15.0

    Formula only, weaned 34.7 35.1 46.3

    Mixed formula and breast milk 26.4 26.8 19.5

    Breast milk only, no formula 28.2 28.0 19.2

    (continued)

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    ≥12 months). Associations of breastfeeding duration with
    WRAVMA scores were null (with narrow 95% CIs).

    Estimated cognitive test mean score differences accord-
    ing to breastfeeding status at age 6 months are given in Table 5.
    Compared with children fed breast milk only, the PPVT-III score
    at age 3 years was approximately 3 points lower for children
    never breastfed and approximately 2 points lower for weaned

    children and those receiving mixed feedings (P = .01 for trend).
    We found a similar trend for the KBIT-II verbal and nonverbal
    scores at age 7 years but observed no appreciable trend for the
    WRAVMA or WRAML scores.

    Compared with children who were never breastfed, the
    fully adjusted PPVT-III score at age 3 years was 1.45 (95% CI,
    −0.98 to 3.87) points higher for children who were ever breast-

    Table 3. Effect of Covariate Adjustment on Estimated Associations of Duration of Any Breastfeeding With Child Cognitiona

    Model

    Points (95% CI) per Month Breastfed

    At Age 3 y

    (n = 1224)

    At Age 7 y

    (n = 1037)

    PPVT-III Score KBIT-II Verbal Score KBIT-II Nonverbal

    Score

    0, Child age and sex 0.58 (0.40 to 0.76) 0.96 (0.77 to 1.14) 0.65 (0.43 to 0.87)

    1, Model 0 plus fetal growth and gestational age 0.57 (0.39 to 0.75) 0.95 (0.76 to 1.14) 0.64 (0.42 to 0.86)

    2, Model 1 plus demographic variablesb 0.29 (0.12 to 0.47) 0.46 (0.28 to 0.65) 0.38 (0.13 to 0.62)

    3, Model 2 plus HOME-SF score 0.29 (0.11 to 0.46) 0.46 (0.27 to 0.64) 0.38 (0.13 to 0.62)

    4, Model 3 plus maternal IQ 0.21 (0.03 to 0.38) 0.35 (0.16 to 0.53) 0.29 (0.05 to 0.54)

    Abbreviations: HOME-SF, Home Observation Measurement of the Environment
    short form; KBIT-II, Kaufman Brief Intelligence Test–Second Edition; PPVT-III,
    Peabody Picture Vocabulary Test–Third Edition.
    a Any breastfeeding through age 12 months.

    b Child race/ethnicity and maternal age, parity, smoking status, depression,
    employment, and child care at 6 months’ post partum, as well as parental
    educational level and marital status, annual household income, and primary
    language.

    Table 2. Included and Excluded Project Viva Mothers and Children (continued)

    Variable

    Included at Age 3
    y

    (n = 1224)
    Included at Age 7 y

    (n = 1037)
    Excluded at Ages 3 and 7 ya

    (n = 771)

    Duration of breastfeeding, mean
    (SE), mo

    Exclusive to age 6 mo 2.4 (0.1) 2.4 (0.1) 1.9 (0.1)

    Any to age 12 mo 6.4 (0.1) 6.5 (0.1) 4.9 (0.2)

    Cognitive test score, mean (SE)

    At age 3 y

    PPVT-III 103.7 (0.43) NA NA

    WRAVMA total 101.8 (0.33) NA NA

    At age 7 y

    KBIT-II verbal NA 112.5 (0.5) NA

    KBIT-II nonverbal NA 106.5 (0.5) NA

    WRAVMA drawing NA 92.2 (0.5) NA

    WRAML visual memory NA 16.9 (0.1) NA

    Family or Household

    HOME-SF score, mean (SE) 18.4 (0.1) 18.4 (0.1) NA

    Annual household income during
    first trimester, %

    <$40 000 14.3 16.2 23.2

    $40 001-$70 000 22.3 21.2 26.4

    >$70 000 63.4 62.6 50.4

    Married or cohabitating during first
    trimester, %

    93.6 92.4 89.3

    Mother’s Partner

    Educational level, %

    ≤High school diploma 13.3 14.2 22.1

    Some college 19.8 20.5 24.7

    Bachelor’s degree 36.5 35.7 30.0

    Graduate degree 30.4 29.6 23.3

    Abbreviations: HOME-SF, Home
    Observation Measurement of the
    Environment short form; KBIT-II,
    Kaufman Brief Intelligence
    Test–Second Edition; NA, not
    applicable; PPVT-III, Peabody Picture
    Vocabulary Test–Third Edition;
    WRAML, Wide Range Assessment of
    Memory and Learning; WRAVMA,
    Wide Range Assessment of Visual
    Motor Abilities.
    a Excluded because of missing

    exposure or outcome data.

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    fed, and the KBIT-II verbal score at age 7 years was 3.75 (1.17-
    6.33) points higher. The WRAVMA and WRAML scores were not
    statistically different (data not shown).

    Stratifying by maternal postpartum fish intake (<2 vs ≥2 servings per week), the relationship between breastfeeding du- ration and the WRAVMA score at age 3 years seemed stronger in children of women with higher vs lower fish intake (Table 6), but the interaction was not statistically significant (P = .16 for interaction). For other cognitive outcomes, associations with breastfeeding duration were not appreciably stronger among children of women who consumed more fish.

    Discussion
    We found that longer duration of breastfeeding and greater
    exclusivity of breastfeeding were associated with better
    receptive language at age 3 years and with higher verbal and
    nonverbal IQ at age 7 years. At age 7 years, the effect size of
    0.35 verbal IQ points per month of any breastfeeding trans-
    lates to 4.2 points, or almost one-third of an SD during 12
    months, whereas the effect size of 0.80 verbal IQ points per
    month of exclusive breastfeeding translates to almost 5
    points over 6 months. Effects were similar in direction but
    somewhat weaker in magnitude for nonverbal IQ and recep-
    tive language at age 3 years. We found no important main
    association of breastfeeding with visual motor skills or
    visual memory.

    While numerous investigations have demonstrated asso-
    ciations of breastfeeding with later cognition, some studies1,4,5

    have had methodological flaws. In particular, adequate con-
    trol for confounding factors is critical because breastfeeding
    and child cognition share many determinants, including ma-
    ternal characteristics and environmental factors. A 2007
    meta-analysis1 identified maternal intelligence and the home
    environment as key confounders that are frequently over-
    looked and found only 1 prior study5 with appropriate adjust-
    ment, an analysis of data from the US National Longitudinal
    Survey of Youth (NSLY) in which the association of breastfeed-
    ing (ever vs never) with achievement scores at ages 5 to 14 years
    was attenuated from 4.7 to 1.3 points after adjustment for ma-
    ternal intelligence and diminished to only 0.5 points after ad-
    justment for sociodemographic and other variables, includ-
    ing the HOME-SF score. We also adjusted for maternal
    intelligence and the HOME-SF score, as well as numerous other
    potential confounders, and nevertheless found a substan-
    tially stronger association (3.75 points) of ever vs never breast-
    fed with verbal IQ at age 7 years.

    It is possible that differences in the degree of breastfeed-
    ing exclusivity explain why we observed a stronger associa-
    tion of breastfeeding with cognition than was seen in the
    NSLY.5 By classifying breastfeeding as ever vs never, the NSLY
    may have included in their breastfed group a substantial
    number of infants who received formula and breast milk,
    biasing results toward the null, but the authors did not report
    the degree of mixed feedings. Differences in breastfeeding
    duration may also explain our discrepant results. In a second-
    ary analysis, the NSLY found that the achievement scores of
    children breastfed for at least 29 weeks were 1.5 points higher
    than those of children never breastfed (P = .01), but the
    authors considered their data about breastfeeding duration
    “less reliable” than data about whether a child was ever

    Figure. Differences in Kaufman Brief Intelligence Test–Second Edition
    Verbal Scores at Age 7 Years According to Duration of Any
    Breastfeeding, With Linear Trend Line

    0

    1-3 4-6 7-9 10-11 ≥12

    7

    5

    6

    Ve
    rb

    al
    IQ

    D
    iff

    er
    en

    ce

    Duration of Any Breastfeeding, mo

    4

    2

    3

    1

    <1

    Estimates are adjusted for child age, sex, fetal growth, gestational age,
    race/ethnicity, and primary language and for maternal age, parity, smoking
    status, IQ, depression, employment, and child care at 6 months’ post partum, as
    well as for parental education level, annual household income, and Home
    Observation Measurement of the Environment short form score.

    Table 4. Adjusted Associations of Duration of Breastfeeding With
    Cognitive Test Scoresa

    Score

    Points (95% CI) per Month Breastfed
    Any Breastfeeding

    to Age 12 mo
    Exclusive Breastfeeding

    to Age 6 mob

    At Age 3 y

    PPVT-III 0.21 (0.03 to 0.38) 0.50 (0.11 to 0.89)

    WRAVMA drawing 0.01 (−0.15 to 0.16) −0.12 (−0.47 to 0.22)

    WRAVMA pegboard 0.09 (−0.06 to 0.24) −0.03 (−0.37 to 0.31)

    WRAVMA matching 0.09 (−0.10 to 0.27) 0.00 (−0.42 to 0.41)

    WRAVMA total 0.08 (−0.07 to 0.23) −0.07 (−0.40 to 0.27)

    At Age 7 y

    KBIT-II verbal 0.35 (0.16 to 0.53) 0.80 (0.38 to 1.22)

    KBIT-II nonverbal 0.29 (0.05 to 0.54) 0.58 (0.01 to 1.14)

    WRAVMA drawing −0.08 (−0.33 to 0.18) −0.05 (−0.62 to 0.53)

    WRAML visual
    memory

    0.04 (−0.02 to 0.11) 0.12 (−0.03 to 0.27)

    Abbreviations: HOME-SF, Home Observation Measurement of the Environment
    short form; KBIT-II, Kaufman Brief Intelligence Test–Second Edition; PPVT-III,
    Peabody Picture Vocabulary Test–Third Edition; WRAML, Wide Range
    Assessment of Memory and Learning; WRAVMA, Wide Range Assessment of
    Visual Motor Abilities.

    a Estimates are adjusted for child age, sex, fetal growth, gestational age,

    race/ethnicity, and primary language and for maternal age, parity, smoking
    status, IQ, depression, employment, and child care at 6 months’ post partum,

    as well as for parental educational level, annual household income, and
    HOME-SF score.

    b No solid foods or non–breast milk liquids (except water).

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    breastfed. Finally, variable outcome measures (achievement
    test score in the NSLY vs IQ in our study) may explain our dif-
    ferent results.

    We identified 4 additional observational studies20-23 that
    adjusted for maternal intelligence and the HOME-SF score.
    While we found a modest association of breastfeeding with
    verbal intelligence at age 3 years, neither of the other 2 pre-
    school studies found an important association with cogni-
    tive outcomes (McCarthy General Cognitive Index21,22 and
    PPVT-Revised22 at age 4 years). Of the studies reporting
    school-age outcomes, one study21 found a 1.3-point (95% CI,
    −2.3 to 4.9) advantage of ever vs never breastfeeding on the
    Wechsler Full-Scale IQ at age 7 years; another study23 found
    a 0.7-point (0.2-1.3) advantage on the same outcome at age 11
    years; and the other study22 found no association with ver-
    bal or performance IQ at age 11 years (effect estimate not

    reported). All those effect estimates are smaller than ours,
    but none of the studies accounted for breastfeeding duration
    or exclusivity.

    Studies of cohorts with different confounding patterns are
    also informative. Brion et al24 analyzed associations of breast-
    feeding duration with IQ at age 8 years in 2 cohorts. In one co-
    hort (the British Avon Longitudinal Study of Parents and Chil-
    dren), breastfeeding duration and child IQ were strongly
    predicted by measures of socioeconomic position, whereas in
    the other cohort (Pelotas, Brazil) child IQ was predicted by so-
    cioeconomic factors, but breastfeeding duration was not. In
    both cohorts, child IQ was strongly associated with breast-
    feeding duration, suggesting that confounding alone did not
    explain the relationship.

    The results of our study are also consistent with a large clus-
    ter randomized trial25 of breastfeeding promotion in which ver-

    Table 5. Adjusted Cognitive Test Score Differences at Ages 3 and 7 Years According to Breastfeeding Status at Age 6 Monthsa

    Score

    Difference in Points (95% CI)

    P Value for TrenddNever Breastfed Weaned Mixed Feedingsb Breast Milk Onlyc

    At Age 3 y

    PPVT-III −3.17 (−5.92 to −0.41) −2.26 (−4.22 to −0.29) −2.27 (−4.24 to −0.30) 0.00 [Reference] .01

    WRAVMA drawing −0.63 (−3.03 to 1.78) −0.01 (−1.74 to 1.72) −0.52 (−2.27 to 1.22) 0.00 [Reference] .80

    WRAVMA pegboard −1.96 (−4.31 to 0.39) −0.36 (−2.05 to 1.34) 0.04 (−1.66 to 1.74) 0.00 [Reference] .18

    WRAVMA matching −1.93 (−4.82 to 0.96) −0.62 (−2.65 to 1.41) −1.13 (−3.21 to 0.96) 0.00 [Reference] .29

    WRAVMA total −2.04 (−4.39 to 0.30) −0.47 (−2.13 to 1.19) −0.75 (−2.42 to 0.93) 0.00 [Reference] .19

    At Age 7 y

    KBIT-II verbal −5.59 (−8.52 to −2.67) −2.96 (−5.05 to −0.88) −1.40 (−3.49 to 0.68) 0.00 [Reference] <.001

    KBIT-II nonverbal −2.71 (−6.62 to 1.21) −3.11 (−5.89 to −0.33) −1.33 (−4.08 to 1.43) 0.00 [Reference] .04

    WRAVMA drawing 0.47 (−3.62 to 4.55) −0.14 (−3.03 to 2.76) −0.73 (−3.61 to 2.15) 0.00 [Reference] .87

    WRAML visual memory −0.67 (−1.72 to 0.39) −0.30 (−1.06 to 0.45) 0.39 (−0.36 to 1.14) 0.00 [Reference] .15

    Abbreviations: HOME-SF, Home Observation Measurement of the Environment
    short form; KBIT-II, Kaufman Brief Intelligence Test–Second Edition; PPVT-III,
    Peabody Picture Vocabulary Test–Third Edition; WRAML, Wide Range
    Assessment of Memory and Learning; WRAVMA, Wide Range Assessment of
    Visual Motor Abilities.
    a Estimates are adjusted for child age, sex, fetal growth, gestational age,

    race/ethnicity, and primary language and for maternal age, parity, smoking
    status, IQ, depression, employment, and child care at 6 months’ post partum,

    as well as for parental educational level, annual household income, and
    HOME-SF score.

    b Breast milk and formula.
    c No formula.
    d P values are calculated in linear regression with breastfeeding category as a

    continuous exposure variable (1 indicates never breastfed; 2, weaned; 3, mixed
    feedings; and 4, breast milk only).

    Table 6. Adjusted Associations of Duration of Breastfeeding With Cognitive Test Scores at Ages 3 and 7 Years by Postpartum Maternal Fish Intakea

    Score

    Points (95% CI) per Month Breastfed P Value for
    Interaction<2 Servings of Fish per Week ≥2 Servings of Fish per Week

    At Age 3 y

    PPVT-III 0.10 (−0.15 to 0.35) 0.30 (0.03 to 0.58) .22

    WRAVMA total −0.01 (−0.22 to 0.20) 0.24 (0.00 to 0.47) .16

    At Age 7 y

    KBIT-II verbal 0.31 (0.06 to 0.56) 0.35 (0.05 to 0.65) .82

    KBIT-II nonverbal 0.36 (0.02 to 0.69) 0.15 (−0.25 to 0.56) .95

    WRAVMA total −0.04 (−0.40 to 0.32) −0.06 (−0.47 to 0.35) .92

    WRAML 0.06 (−0.03 to 0.16) 0.04 (−0.06 to 0.14) .75

    Abbreviations: HOME-SF, Home Observation Measurement of the Environment
    short form; KBIT-II, Kaufman Brief Intelligence Test–Second Edition; PPVT-III,
    Peabody Picture Vocabulary Test–Third Edition; WRAML, Wide Range
    Assessment of Memory and Learning; WRAVMA, Wide Range Assessment of
    Visual Motor Abilities.

    a Estimates are adjusted for child age, sex, fetal growth, gestational age,
    race/ethnicity, and primary language and for maternal age, parity, smoking
    status, IQ, depression, employment, and child care at 6 months’ post partum,
    as well as for parental educational level, annual household income, and
    HOME-SF score.

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    bal IQ at age 6.5 years was 7.5 points (one-half of an SD) higher
    in the breastfeeding promotion group. By design, that study
    minimized confounding by measured and unmeasured fac-
    tors; however, nonblinding of clinicians assessing the cogni-
    tive outcomes to participant breastfeeding status suggests the
    potential for bias. Together, the results of the well-controlled
    observational studies20-23 (including ours), the analysis of co-
    horts without social patterning of breastfeeding (eg, in the Pelo-
    tas cohort),24 and the large randomized trial25 suggest that con-
    founding does not account fully for the observed association
    of breastfeeding with later cognition.

    In analyses stratified by fish intake, the beneficial effects
    of breastfeeding on visual motor ability at age 3 years seemed
    greater for women who consumed 2 or more servings com-
    pared with less than 2 servings per week, although the inter-
    action was not statistically significant. This observation is con-
    sistent with the hypothesis that 1 or more nutrients in fish
    transfer to breast milk and account for some of the observed
    beneficial effect and is relevant to optimizing the maternal diet
    during lactation. Docosahexaenoic acid is incorporated in large
    amounts into cell membranes of the developing retina and
    brain. Its content in breast milk is variable26 and depends on
    DHA sources in the maternal diet,6,27 including fish; infant DHA
    status in turn depends on the DHA content of ingested breast
    milk.27 Randomized trials of DHA supplementation during lac-
    tation have found beneficial effects of DHA on early motor
    skills28 and sustained attention29 but not visual motor func-
    tion or general cognition.28,30 Our observation may be ex-
    plained by DHA or nutrients in fish other than DHA. It may also
    be a chance finding.

    Strengths of our study include a prospective design, de-
    tailed contemporaneous measurement of duration and exclu-
    sivity of breastfeeding, and measurement of numerous poten-
    tial confounding variables, including the home environment and
    maternal IQ. As in all observational studies, confounding by un-
    measured factors is possible and may have led us to overesti-
    mate the true effect of breastfeeding, although our results are
    consistent with data from a randomized trial25 of breastfeed-
    ing promotion that eliminates confounding by design. We mea-
    sured cognition at school age, which tends to be stable through
    adulthood31 compared with measurement in preschool or ear-
    lier. The elevated socioeconomic status and high breastfeed-
    ing rate of our cohort may limit generalizability of the study find-
    ings. In addition, we followed up only a subset of the original
    Project Viva cohort to ages 3 and 7 years. The children we ob-
    served tended to be of higher socioeconomic status and were
    less likely to be of minority race/ethnicity than the children we
    did not follow up, which could have led to overestimates if the
    effect of breastfeeding on cognition was much weaker or in the
    opposite direction in those who dropped out, situations we find
    unlikely. Finally, for the statistically significant associations of
    breastfeeding with later cognition, 95% CIs were narrow and ex-
    clude a null result, but the lower confidence limits include val-
    ues with little clinical importance.

    In summary, our results support a causal relationship of
    breastfeeding in infancy with receptive language at age 3 and
    with verbal and nonverbal IQ at school age. These findings sup-
    port national and international recommendations to pro-
    mote exclusive breastfeeding through age 6 months and con-
    tinuation of breastfeeding through at least age 1 year.

    ARTICLE INFORMATION

    Accepted for Publication: February 6, 2013.

    Published Online: July 29, 2013.
    doi:10.1001/jamapediatrics.2013.455.

    Author Contributions: Study concept and design:
    Belfort, Kleinman, Gillman, Oken.
    Acquisition of data: Bellinger, Gillman, Oken.
    Analysis and interpretation of data: Belfort,
    Rifas-Shiman, Kleinman, Guthrie, Bellinger, Taveras,
    Oken.
    Drafting of the manuscript: Belfort.
    Critical revision of the manuscript for important
    intellectual content: All authors.
    Statistical analysis: Belfort, Rifas-Shiman, Kleinman,
    Guthrie.
    Obtained funding: Belfort, Gillman, Oken.
    Administrative, technical, and material support:
    Gillman.
    Study supervision: Bellinger, Taveras, Gillman, Oken.

    Conflict of Interest Disclosures: None.

    Funding/Support: This work was supported by
    grants K23 DK083817 (Dr Belfort), K24 HL68041
    (Dr Gillman), K24 HD069408 (Dr Oken), R01
    ES016314, R01 HD34568, and R01 HL64925 from
    the National Institutes of Health.

    REFERENCES

    1. Ip S, Chung M, Raman G, et al. Breastfeeding and
    maternal and infant health outcomes in developed
    countries. Evid Rep Technol Assess (Full Rep).
    2007;(153):1-186.

    2. Jain A, Concato J, Leventhal JM. How good is the
    evidence linking breastfeeding and intelligence?
    Pediatrics. 2002;109(6):1044-1053.

    3. Anderson JW, Johnstone BM, Remley DT.
    Breast-feeding and cognitive development: a
    meta-analysis. Am J Clin Nutr. 1999;70(4):525-535.

    4. Drane DL, Logemann JA. A critical evaluation of
    the evidence on the association between type of
    infant feeding and cognitive development. Paediatr
    Perinat Epidemiol. 2000;14(4):349-356.

    5. Der G, Batty GD, Deary IJ. Effect of breast
    feeding on intelligence in children: prospective
    study, sibling pairs analysis, and meta-analysis. BMJ.
    2006;333(7575):e945. http://
    www.ncbi.nlm.nih.gov/pmc/articles/PMC1633819/.
    Accessed June 15, 2013.

    6. Jensen CL, Maude M, Anderson RE, Heird WC.
    Effect of docosahexaenoic acid supplementation of
    lactating women on the fatty acid composition of
    breast milk lipids and maternal and infant plasma
    phospholipids. Am J Clin Nutr. 2000;71(1)(suppl):
    292S-299S.

    7. Oken E, Radesky JS, Wright RO, et al. Maternal
    fish intake during pregnancy, blood mercury levels,
    and child cognition at age 3 years in a US cohort.
    Am J Epidemiol. 2008;167(10):1171-1181.

    8. Oken E, Kleinman KP, Olsen SF, Rich-Edwards
    JW, Gillman MW. Associations of seafood and
    elongated n-3 fatty acid intake with fetal growth
    and length of gestation: results from a US

    pregnancy cohort. Am J Epidemiol.
    2004;160(8):774-783.

    9. Gillman MW, Rifas-Shiman SL, Kleinman KP,
    Rich-Edwards JW, Lipshultz SE. Maternal calcium
    intake and offspring blood pressure. Circulation.
    2004;110(14):1990-1995.

    10. Taveras EM, Rifas-Shiman SL, Scanlon KS,
    Grummer-Strawn LM, Sherry B, Gillman MW. To
    what extent is the protective effect of
    breastfeeding on future overweight explained by
    decreased maternal feeding restriction? Pediatrics.
    2006;118(6):2341-2348.

    11. Williams KT, Wang J-J. Technical References to
    the Peabody Picture Vocabulary Test–Third Edition
    (PPVT-III). Circle Pines, MN: American Guidance
    Service Inc; 1997.

    12. Adams W, Sheslow D. WRAVMA (Wide Range
    Assessment of Visual Motor Abilities). Wilmington,
    DE: Wide Range Inc; 1995.

    13. Grados JJ, Russo-Garcia KA. Comparison of the
    Kaufman Brief Intelligence Test and the Wechsler
    Intelligence Scale for Children–Third Edition in
    economically disadvantaged African American
    youth. J Clin Psychol. 1999;55(9):1063-1071.

    14. Adams W, Sheslow D. Wide Range Assessment
    of Memory and Learning Administration and
    Technical Manual. 2nd ed. Lutz, FL: Psychological
    Assessment Resources Inc; 2001.

    15. Gillman MW, Rich-Edwards JW, Rifas-Shiman
    SL, Lieberman ES, Kleinman KP, Lipshultz SE.

    Infant Feeding and Childhood Cognition Original Investigation Research

    jamapediatrics.com JAMA Pediatrics September 2013 Volume 167, Number 9 843

    Downloaded From: http://archpedi.jamanetwork.com/ by Eliza Dean on 02/04/2016

    Maternal age and other predictors of newborn
    blood pressure. J Pediatr. 2004;144(2):240-245.

    16. Fawzi WW, Rifas-Shiman SL, Rich-Edwards JW,
    Willett WC, Gillman MW. Calibration of a
    semi-quantitative food frequency questionnaire in
    early pregnancy. Ann Epidemiol. 2004;14(10):
    754-762.

    17. Frankenburg WK, Coons CE. Home Screening
    Questionnaire: its validity in assessing home
    environment. J Pediatr. 1986;108(4):624-626.

    18. Oken E, Kleinman KP, Rich-Edwards J, Gillman
    MW. A nearly continuous measure of birth weight
    for gestational age using a United States national
    reference. BMC Pediatr. 2003;3:e6.
    http://www.biomedcentral.com/1471-2431/3/6.
    Accessed June 15, 2013.

    19. Horton NJ, Kleinman KP. Much ado about
    nothing: a comparison of missing data methods and
    software to fit incomplete data regression models.
    Am Stat. 2007;61(1):79-90.

    20. Morrow-Tlucak M, Haude RH, Ernhart CB.
    Breastfeeding and cognitive development in the
    first 2 years of life. Soc Sci Med. 1988;26(6):
    635-639.

    21. Wigg NR, Tong S, McMichael AJ, Baghurst PA,
    Vimpani G, Roberts R. Does breastfeeding at six

    months predict cognitive development? Aust N Z J
    Public Health. 1998;22(2):232-236.

    22. Jacobson SW, Chiodo LM, Jacobson JL.
    Breastfeeding effects on intelligence quotient in 4-
    and 11-year-old children. Pediatrics.
    1999;103(5):e71. http://www.biomedcentral.com
    /1471-2431/3/6. Accessed June 15, 2013.

    23. Hay DF, Pawlby S, Sharp D, Asten P, Mills A,
    Kumar R. Intellectual problems shown by
    11-year-old children whose mothers had postnatal
    depression. J Child Psychol Psychiatry.
    2001;42(7):871-889.

    24. Brion MJ, Lawlor DA, Matijasevich A, et al.
    What are the causal effects of breastfeeding on IQ,
    obesity and blood pressure? evidence from
    comparing high-income with middle-income
    cohorts. Int J Epidemiol. 2011;40(3):670-680.

    25. Kramer MS, Aboud F, Mironova E, et al;
    Promotion of Breastfeeding Intervention Trial
    (PROBIT) Study Group. Breastfeeding and child
    cognitive development: new evidence from a large
    randomized trial. Arch Gen Psychiatry.
    2008;65(5):578-584.

    26. Brenna JT, Varamini B, Jensen RG,
    Diersen-Schade DA, Boettcher JA, Arterburn LM.

    Docosahexaenoic and arachidonic acid
    concentrations in human breast milk worldwide.
    Am J Clin Nutr. 2007;85(6):1457-1464.

    27. Sanders TA, Reddy S. The influence of a
    vegetarian diet on the fatty acid composition of
    human milk and the essential fatty acid status of the
    infant. J Pediatr. 1992;120(4, pt 2):S71-S77.

    28. Jensen CL, Voigt RG, Prager TC, et al. Effects of
    maternal docosahexaenoic acid intake on visual
    function and neurodevelopment in breastfed term
    infants. Am J Clin Nutr. 2005;82(1):125-132.

    29. Cheatham CL, Nerhammer AS, Asserhøj M,
    Michaelsen KF, Lauritzen L. Fish oil
    supplementation during lactation: effects on
    cognition and behavior at 7 years of age. Lipids.
    2011;46(7):637-645.

    30. Campoy C, Escolano-Margarit MV, Anjos T,
    Szajewska H, Uauy R. Omega 3 fatty acids on child
    growth, visual acuity and neurodevelopment. Br J
    Nutr. 2012;107(suppl 2):S85-S106.

    31. Sattler JM. Assessment of Children: Cognitive
    Applications. 4th ed. San Diego, CA: Jerome M.
    Sattler Inc; 2001.

    Research Original Investigation Infant Feeding and Childhood Cognition

    844 JAMA Pediatrics September 2013 Volume 167, Number 9 jamapediatrics.com

    Downloaded From: http://archpedi.jamanetwork.com/ by Eliza Dean on 02/04/2016

    Developed by Ron Lally and Cathy Tsao. © 2004, WestEd, The Program for Infant/Toddler Care.
    This document may be reproduced for educational purposes.

    Definition
    The concept of continuity of care refers to the policy of assigning a primary caregiver to an
    infant at the time of enrollment in a child care program and continuing this relationship until the
    child is at least three years old.

    With continuity, the infant is not moved to a new group; either the entire group moves with the
    caregiver to another space more appropriate for older infants, or the caregiver modifies the
    environment to meet the children’s changing needs. The most important relationship to
    continue is the one between the child and the primary caregiver, but promoting long-term
    relationships with other caregivers and with other children in the group is also important.

    Foundation: Theory and Research
    In attachment theory, stability and consistency of caregivers are seen as important factors in the
    development and maintenance of secure attachment relationships (Bowlby, 1973). Children
    take a significant amount of time to form attachments to caregivers, so they are less likely to
    form attachments if frequent caregiver changes occur. More frequent changes in primary
    caregiver have been associated with negative child outcomes, including withdrawing behaviors
    and higher levels of aggression as preschoolers (Howes & Hamilton, 1993).

    On the other hand, time with a high-ability teacher has been positively associated with security
    of attachment in infant day care (Raikes, 1993). When infants are able to develop a relationship
    with a teacher over time, the infant-teacher relationship becomes more defined and predictable,
    creating a secure base for the infant. Raikes (1993) found that attachment security increased
    as children spent more time with their primary caregivers, and that 91% of infants who had been
    with their teacher for over one year were categorized as securely attached. These results are
    consistent with attachment theory, which suggests that time in a relationship is required in order
    for secure attachments to develop. However, the theory does not imply that time with an
    insensitive or non-responsive teacher would also promote security in infant-teacher attachment;
    in fact, such an arrangement may lead to the infant’s developing an insecure relationship with
    the teacher. The quality with which the teacher interacts with the child is key.

    Context
    There is a clear link between child care quality and child outcomes, where child care quality is
    defined by either structural variables, which can be regulated, such as group size and continuity
    of care; or process variables, which require judgment and interpretation, and are difficult or
    impossible to regulate, such as sensitive and responsive caregiving (Howes, Phillips, &
    Whitebook, 1992). Structural variables are thought to influence process variables, and
    researchers (Raikes, 1993) have conceptualized the infant-teacher relationship as a mediator
    between child care quality and child outcomes.

    Continuity of Care

    2

    Research and theory have established the necessity of intimate caregiving relationships for
    laying a foundation of trust, providing predictability, regulating attention, and creating interest for
    infants. Raikes (1993) hypothesizes that “time with teacher”—the length of time a high-ability
    teacher cares for an infant—is an indicator of quality for the infant-teacher relationship.

    Structural Variables
    In the context of the PITC philosophy’s six essential policies1, continuity supports the secure,
    warm relationships infants and toddlers need in order to thrive. Continuity begins with
    assignment of a primary caregiver who develops a close relationship with the child and the
    family and is primarily responsible for the child’s care. These relationships—and all
    relationships in the setting—are supported by the organization of caregivers and children into
    small groups. These three program policies—primary care, small groups, and continuity—
    promote feelings of security and predictability for infants and toddlers in group care. These
    policies work best together, but any one of them will improve the quality of care.

    Process Variables
    The ideal match is between program policies that support relationships and highly sensitive
    teachers who implement those policies. In addition to the three policies described above, other
    components of the PITC philosophy—responsive caregiving, culturally sensitive care and family
    support, and attention to temperamental differences—contribute to the quality of interactions.
    With a working knowledge of these components teachers become increasingly able to provide
    appropriate infant care and family support.

    Barriers
    Among continuity, primary caregiving, and small groups, the concept of continuity is the most
    likely to encounter resistance, in part because it is the newest idea. In a study of child care
    centers across the United States, the practice of continuity of care was found to be rare (Cryer,
    Hurwitz, & Wolery, 2000). While the infant’s need for close relationships is incontrovertible, the
    idea that we can and should promote long-term relationships in infant/toddler programs
    challenges us to new heights at a time when many programs are consumed with basic survival.
    Teachers and administrators need support and information to help them in the process of
    implementation of continuity of care and to ensure the entire staff believes in its role in the
    development of relationships and healthy attachment. Without disregarding the real-life
    concerns that programs face, we can strive to set the bar—rather than aim for the lowest
    common denominator—by encouraging programs to take one step at a time and to move
    steadily to the provision of continuity.

    Structuring infant/toddler programs to promote long-term relationships often means reorganizing
    the environment, staffing, training, admission policies—the very systems by which we staff,
    enroll and care for children. It raises logistical questions that cannot be answered in the
    abstract, e.g., safety regulations, subsidy requirements, age-related fee and reimbursement
    schedules. Every program needs to find its own solutions to the arrangement of space and
    equipment, the scheduling of children and caregivers, staffing ratios and group size, etc.

    Ultimately, continuity of child care relationships—along with small groups and primary
    caregiving assignments—benefit everyone in a program, promoting staff and family cooperation

    1 PITC’s six essential policies are continuity, primary caregiving, small groups, individualized care,
    cultural sensitivity, and inclusion of children with special needs.

    3

    and loyalty; creating a calmer, less stressful environment; and providing better opportunities for
    the growth and development of adults as well as children.

    References

    Barnas, M.V., & Cummings, E.M. (1994). Caregiver stability and toddlers’ attachment-related

    behavior towards caregivers in day care. Infant Behavior and Development, 17, 141 –
    147.

    Bowlby, J. (1973). Attachment and loss, Vol. 2: Separation. London: Basic Books.

    Cryer, D., Hurwitz, S., & Wolery, M. (2000). Continuity of caregiver for infants and

    toddlers in center-based child care: Report on a survey of center practices. Early
    Childhood Research Quarterly, 15(4), 497 – 514.

    Howes, C., & Hamilton, C.E. (1993). The changing experience of child care: Changes in

    teachers and in teacher-child relationships and children’s social competence with peers.
    Early Childhood Research Quarterly, 8, 15 – 32.

    Howes, C., Phillips, D.A., & Whitebook, M. (1992). Thresholds of quality: Implications for the

    social development of children in center-based child care. Child Development, 63, 449 –
    460.

    Raikes, H. (1993). Relationship duration infant care: Time with a high-ability teacher and infant-

    teacher attachment. Early Childhood Research Quarterly, 8, 309 – 325.

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    Clinical digest

    NEW EVIDENCE ADDS TO
    THE BREAST VERSUS
    BOTTLE-FEEDING DEBATE
    UK research compares temperaments
    of babies fed by different methods

    New mothers should be informed that it is
    normal for breastfed babies to cry more and
    appear less content than bottle-fed babies.

    The Medical Research Council asked mothers
    to assess the temperaments of their babies at
    three months using a behaviour questionnaire.
    Of the 316 babies, 137 were exclusively
    breastfed, 88 were fed with formula milk and
    91 were fed with a combination.

    Overall, breast and mixed-fed babies were
    rated by their mothers as having more
    challenging temperaments. Compared to
    formula-fed babies, breastfed babies showed
    greater distress, and were less likely to smile,
    laugh or vocalise. They were also slower to calm
    down following distress or excitement.

    Lead researcher Ken Ong, a paediatrician from
    the Medical Research Council epidemiology unit
    in Cambridge, says: ‘Bottle-fed babies may
    appear more content, but research suggests
    that they could gain weight too quickly.

    ‘Rather than being put off breastfeeding,
    parents should have more realistic expectations

    of normal infant
    behaviour and should

    receive better
    support to cope
    with difficult infant
    behaviours if needed.’
    The Department of

    Health recommends
    breastfeeding for the

    first six months, but most
    UK mothers switch to

    bottle-feeding within
    four months.
    de Lauzon-Guillain
    B et al (2012)

    Breastfeeding
    and infant
    temperament
    at age three
    months.

    PLoS One. doi:
    10.1371/journal.
    pone.0029326.

    says more large studies are
    needed to establish whether
    red meat is a risk factor for
    pancreatic cancer.

    She adds: ‘Stopping smoking
    is the best way to reduce your
    chances of developing many
    types of cancer – and other
    diseases too.’
    Larsson SC et al (2012) Red and
    processed meat consumption
    and risk of pancreatic cancer:
    meta-analysis of prospective studies.
    British Journal of Cancer.
    doi: 10.1038/bjc.2011.585.

    Bariatric surgery could have
    more pronounced ‘benefits’
    than standard lifestyle changes

    Weight-loss surgery reduces the
    risk of heart attacks and other
    cardiovascular events, according
    to research conducted as part
    of the Swedish Obese Subjects
    (SOS) study.

    SOS is an ongoing study
    of 2,010 participants who
    underwent bariatric surgery
    and a control group of 2,037
    individuals who received usual
    (non-surgical) care for their
    obesity. Patients were aged
    37 to 60, with a body mass
    index of at least 34 in men and
    at least 38 in women.

    They were recruited between
    1987 and 2001 and there was
    a mean follow-up of 14.7 years.
    Surgery patients underwent
    vertical banded gastroplasty
    (68.1 per cent), gastric bypass
    (13.2 per cent) and banding
    (18.7 per cent).

    At two years follow-up, the
    mean change in body weight in
    surgery patients was a decrease
    of 23 per cent; at ten years the
    decrease was 16 per cent, at
    20 years it was 18 per cent. In
    the control group, there was no
    change in body weight at two
    years follow-up and only a 1 per
    cent decrease at 15 and 20 years.

    Swedish research establishes
    link between eating processed
    meat and pancreatic cancer

    Eating processed meat increases
    the risk of pancreatic cancer,
    suggests a study that also found
    red meat increases the risk of
    the cancer in men.

    Researchers at the Karolinksa
    Institutet in Stockholm, Sweden,
    conducted a meta-analysis of
    11 studies involving 6,643
    pancreatic cancer cases. They
    found that for each 50 grams of
    processed meat eaten each day –
    equivalent to one sausage or two
    rashers of bacon – there was a
    19 per cent rise in the risk of
    pancreatic cancer compared
    to those who ate no meat.
    Consuming 150g of processed
    meat per day increased the risk
    by 58 per cent.

    The evidence for red meat
    was inconclusive, with an
    increase in risk for men, but
    not for women. Men who ate
    120g per day of red meat had
    a 29 per cent increased risk of
    pancreatic cancer compared
    to those who ate no meat.

    Study author Susanna Larsson
    says that pancreatic cancer’s
    poor survival rate means it is
    important to understand the
    factors that increase the risk
    of the disease. ‘If diet affects
    pancreatic cancer then this
    could influence public health
    campaigns to help reduce the
    number of cases of this disease
    developing in the first place.’

    Cancer Research UK
    information director Sara Hiom

    NURSING STANDARD

    A
    LA

    M
    Y

    IS

    TO

    C
    K

    PH
    O

    TO

    p16-17w22_CLINICAL DIGEST this one copy 5 30/01/2012 12:13 Page 16

    Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

    PEDIATRIC REVIEW

    The role of responsive feeding in overweight during
    infancy and toddlerhood: a systematic

    review

    KI DiSantis1, EA Hodges2, SL Johnson3 and JO Fisher

    4

    1Center for Clinical Epidemiology and Biostatistics, School of Medicine, University of Pennsylvania, Philadelphia, PA, USA;
    2Family Health Division, School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA;
    3Department of Pediatrics, Section of Nutrition, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA and
    4Department of Public Health, Temple University, Center for Obesity Research and Education, Philadelphia, PA, USA

    A chronic mismatch of caregiver responsiveness to infant-feeding cues, such as feeding when the infant is not hungry, is
    hypothesized to have a role in the development of overweight by impairing an infant’s response to internal states of hunger and
    satiation. Although this concept of mismatch or discordance has long been acknowledged in scholarly writings, a systematic
    assessment of the evidence supporting the role of discordant responsiveness during infant feeding in the early origins of
    overweight is lacking. This review was undertaken to assess evidence for this hypothesized relationship between discordant
    responsiveness in feeding and overweight in infancy and toddlerhood, framed within the larger social-environmental context of
    the infant–caregiver dyad. A systematic method was used to extract articles from three databases of the medical, psychology
    and nursing fields. The quality of evidence collected was assessed using Oxford University Centre for Evidence Based Medicine’s
    level of evidence and through a narrative review. The systematic search resulted in only nine original research studies, which met
    a priori inclusion/exclusion criteria. Several studies provide support for the conceptual model, but most were cross-sectional or
    lower quality prospective studies. The need for consistent definitions, improved measures and longitudinal work is discussed.
    In conclusion, this review reveals preliminary support for the proposed role of discordant responsiveness in infant/child overweight
    and at the same time highlights the need for rigorous investigation of responsive feeding interactions in the first years of life.

    International Journal of Obesity

    (2011) 35, 480–492; doi:10.1038/ijo.2011.3; published online 22 March 2011

    Keywords: infant; feeding behavior; responsiveness; appetite regulation; self-regulation; overweight

    Introduction

    Infancy is believed to be a sensitive period for the develop-

    ment of energy intake regulation1 and overweight.2–6 In the

    first 2 years of life, infants and toddlers are dependent on

    their caregivers to provide adequate and appropriate nutri-

    tion. For this reason, the potential influence of feeding

    dynamics on overnutrition and the development of over-

    weight is seemingly intuitive. Scholarly work on early life

    origins of overweight, however, has largely ignored the

    possible impacts of social and behavioral transactions on

    infant feeding. We focus on one particular aspect of these

    caregiver–infant transactions: responsive feeding. In this

    review, we define responsiveness within the context of

    overweight, as involving prompt, contingent and develop-

    mentally appropriate responses to the infant’s hunger and

    satiety cues. As the review will describe, the degree to which

    feeding interactions are responsive is believed to hold

    importance in infant development by nurturing or impeding

    the development of self-regulation. Self-regulation, generally

    defined as ‘the ability to regulate reactionsyand to function

    more independently in a personal and social context, (pg 93)’

    is said to have multi-dimensional influence on functioning,

    including behavioral, emotional and cognitive actions.7 The

    early development of this general capacity is profoundly

    affected by supportive caregiver–infant interactions and it is

    likely that these interactions have a similar impact on the

    development of eating self-regulation. We present a model in

    which a caregiver’s responsiveness that is congruent with

    infant-feeding cues encourages the development of infant self-

    regulation as it relates to energy intake, and eventually obesity.

    Overweight and accelerated weight gain in infancy
    and toddlerhood

    The problem of pediatric overweight is evident before the

    preschool years. Data collected in the National Health and
    Received 21 June 2010; revised 6 December 2010; accepted 26 December

    2010; published online 22 March 2011

    Correspondence: Dr KI DiSantis, School of Medicine, Center for Clinical

    Epidemiology and Biostatistics, University of Pennsylvania, 8th floor Blockley

    Hall, 423 Guardian drive, Philadelphia PA 19104, USA.

    E-mail: disantis@med.mail.upenn.edu

    International Journal of Obesity (2011) 35, 480–

    492

    & 2011 Macmillan Publishers Limited All rights reserved 0307-0565/11

    www.nature.com/ijo

    http://dx.doi.org/10.1038/ijo.2011.3

    mailto:disantis@med.mail.upenn.edu

    http://www.nature.com/ijo

    Nutrition Examination Survey 2007–2008 indicated that

    approximately 10% of infants and toddlers were above the

    95th percentile for weight-for-length; the prevalence was as

    high as 14.9% in Hispanic males.8 These numbers are

    of concern because heavy infants are at increased risk of

    overweight in later stages of development.9,10 Analysis of the

    CDC Pediatric Nutrition Surveillance System data revealed

    that overweight infants (0–11 months) were 2.9–4.3 times

    more likely to be overweight between the ages of 1 and 4

    years than non-overweight infants.11 Accelerated weight

    gain during the first 2 years of life, independent of birth

    weight and parental weight status, has also been associated

    with a greater risk of overweight during childhood12–17 and

    young adulthood4,18–21 (see Stettler and Iotova22 for a

    review). Though discussion of etiology has favored biological

    explanations, caregiver–infant feeding interaction, like re-

    sponsiveness, is implicit when considering the potential

    contributing factors of infant weight gain.14,23

    Caregiving and self-regulation among infants and
    toddlers

    Why might caregiver responsiveness be a formative dimen-

    sion of feeding during the first 2 years of life?

    Responsiveness

    is a dimension of infant–caregiver interactions, which has

    been said to shape an infant’s ability to acquire self-

    regulation.7 Early relationships with caregivers engender an

    infant’s development in numerous ways, but a supportive

    environment to enhance the development of self-regulation

    of energy intake holds unique importance for childhood

    obesity risk. Supporting infant self-regulation of energy

    intake may provide the necessary conditions to facilitate

    development of regulatory capacity and autonomy through-

    out infancy and into childhood. It is believed that infants

    and young children are born with a nascent capacity for self-

    regulation that becomes actualized through cause–effect

    learning, which occurs when their behavior is consistently

    met with a prompt, developmentally appropriate response.24

    Responsive caregiving has been studied for decades in

    domains outside of child feeding and growth, and has been

    positively associated with a wide range of developmental

    outcomes in infancy and early childhood including

    emotional, language and cognitive capacity, as well as the

    security of attachment to the mother (see Ziv et al.25 for a

    review). Such synchronous interactions are thought to

    provide fundamental support for opportunities to learn

    mastery and self-regulation.26 Early infant emotions, for

    example, stem from physical states, including temperature,

    sleep states and hunger.7 Newborns exhibit emotional

    reactivity to these physical states and express discomfort

    via crying, but begin to show signs of self-regulated behavior

    by 3 months of age.27 Examples of self-regulated behavior

    include turning the body or head away from undesirable

    stimuli and moving the hands toward the head and mouth.7

    Caregivers support this developmental progression from

    emotional reactivity to self-regulation by their consistent,

    accurate and appropriate responses to infant cues, which

    foster expectations in the developing infant about predict-

    able patterns of interaction.7 However, accurate interpreta-

    tion by caregivers is complicated by the fact that infant

    crying can reflect discomfort due a variety of physical states

    including sleep, temperature and hunger states.28 Thus, it

    should be acknowledged that caregiver and child are

    mutually influencing one another over time through the

    consistency, meaning and appropriate interpretation of one

    another’s behaviors.

    Caregiver influences on the infant’s development of

    self-regulation of feeding behavior parallels emotional devel-

    opment. In their monthly feeding observations of 26 mother–

    infant pairs over the first year of life, Ainsworth and Bell29

    observed that mothers who exhibited more sensitive pacing

    and prompt responses to the infant during feeding had infants

    who cried less in early infancy and demonstrated greater

    attachment to their mothers at the end of the first year,

    compared with mothers who adhered to rigid feeding

    schedules. This supports the hypothesis that caregiver respon-

    sivity affects infant outcomes and development.30,31 However,

    the relationship between caregiver and infant is bidirectional

    and can also be affected by the clarity of infant cues.32,33 Some

    infants demonstrate ambiguous signals, and have fewer

    behaviors in general, including fewer elicited and spontaneous

    vocalizations, fewer smiles, less gaze and joint attention and

    poor signals to indicate their needs (including hunger cues). In

    such cases, a caregiver’s responsiveness might be discordant

    with infant needs (due to poor clarity of cues) or might be a

    low level because few cues are exhibited.

    To this notion, Wright and colleagues34,35 have argued

    that appropriate responses to infant-feeding cues are critical

    for self-regulation and self-control of food intake to develop

    to its fullest potential. This argument is evidenced by

    experimental studies, which have demonstrated that infants

    as young as 6 weeks of age could adjust the volume of

    formula intake in response to its energy content to maintain

    daily energy intake.36–38 Observational research has also

    provided evidence of such a capacity, including data from

    3022 children (6 to 24 month old ) participating in the

    Feeding Infants and Toddlers Study showing inverse relation-

    ships between the number of daily feeds and the size of

    feeds.39 In the context of developmental literature on

    responsive parenting, self-regulation of energy intake in

    infancy and toddlerhood is viewed as the extent to which

    feeding environments and interactions allow the biological

    potential of the child for self-regulation to be actualized.40

    A potential role for responsive feeding

    Although contribution of responsive feeding to self-regula-

    tion and overweight in early development has been

    Responsive feeding and infant overweight
    KI DiSantis et al

    481

    International Journal of Obesity

    suggested in scholarly writings for decades,35,41–44 systematic

    inquiry appears limited. This review was undertaken to

    characterize empirical support for the assertion that varia-

    tion in the concordance of a caregiver’s responsiveness and

    an infant’s hunger and satiety cues has a fundamentally

    important role in growth by supporting energy self-regula-

    tion in infancy and toddlerhood. Figure 1 presents the

    conceptual framework that guided the review by articulating

    potential pathways through which caregiver responsiveness

    to infant-feeding cues influences child intake and growth.

    Drawing from the developmental literature, feeding respon-

    siveness is defined for the purposes of this review as prompt,

    contingent and developmentally appropriate responses to

    the child’s hunger and satiety cues.24,45 The bidirectional

    nature of feeding is implicit in this definition, with the

    caregiver dependent on the infant to provide clear, un-

    ambiguous cues and the infant dependent on the caregiver’s

    accurate interpretation of and appropriate response to those

    cues for obtaining adequate and appropriate nutrition.

    Given the aforementioned variance in the clarity of infant-

    feeding cues, caregivers may be challenged to a lesser or

    greater degree in their interpretation of cues. Likewise, less-

    responsive caregivers may challenge the infant to provide

    clearer cues (within a repertoire that may be relatively

    limited in the first months of life). Thus, when we refer to

    caregiver feeding responsiveness, we are referring to a

    characteristic of the caregiver–child dyad’s level of concor-

    dance in interactions during feeding. Responsiveness to

    child-feeding cues has previously been included as part of an

    internationally recognized framework of infant-care

    practices oriented toward the prevention of malnutrition

    and the support of child mental, social and physical

    development.31,44,46 In that work, responsive feeding has

    been broadly conceptualized to involve the caregiver’s

    adaptation to the child’s psychomotor abilities for feeding

    and provision of a structured feeding environment with a

    goal of facilitating energy consumption to offset the effects

    of malnutrition.44 In contrast, this review focuses solely on

    the role of caregiver responsiveness to feeding cues in

    supporting the capacity of infants to self-regulate energy

    intake for optimal growth in a context of obesity risk.

    Figure 1 was developed drawing from scholarly writing

    dating back almost a half century.35,41–44 In this model,

    discordant caregiver responsiveness to infant cues, specifi-

    cally feeding without hunger and feeding beyond satiety, is

    hypothesized to impair infant-satiety response. Such impair-

    ments are suggested to promote energy intake beyond needs

    for growth via increases in meal size and/or feeding

    frequency. Overweight and rapid weight gain during infancy

    and toddlerhood are the main growth-related outcomes of

    interest. This model acknowledges feeding responsiveness as

    being nested within a broader social-environmental context

    that influences the way in which caregivers feed their

    children,47 including cultural influences (e.g., ethnicity/

    race48), policy and prevailing feeding guidance (e.g., World

    Health Organization Recommendations on Breastfeeding49),

    parental beliefs/goals/values,50 and parental knowledge of

    development.51 These are all the factors brought in to the

    feeding relationshipFand all can have considerable effects

    on the relationship. This model acknowledges these ele-

    ments, which are at the foundation of building a responsive

    feeding relationship. The review was initiated to assess the

    amount and quality of empirical evidence available to

    support this

    proposed model.

    Materials and methods

    Literature-search strategy

    We performed a systematic literature review of responsive

    feeding using the three major databases from three dis-

    ciplines (medicine, psychology and nursing): MEDLINE via

    PubMed (United States National Library of Medicine,

    Bethesda, MD, USA), PsycINFO (American Psychological

    Association, Washington, DC, USA) and CINAHL (Ebscohost,

    Glendale, CA, USA). These databases were searched for

    articles listed from the database’s inception to September

    2009. Database limits were used to restrict the search to

    research in humans and infants (from birth to 24 months).

    As listed in Table 1, a list of 25 search terms were generated

    by the research team to identify relevant articles addressing

    Accelerated Weight Gain/
    Overweight

    Accelerated Weight Gain/
    Overweight

    Infant
    Caregiver

    Clarity of Hunger
    and Satiety Cues

    Discordant
    Feeding

    Responsiveness

    Discordant
    Feeding

    Responsiveness

    Increased Feeding
    Frequency/Amount
    Increased Feeding
    Frequency/Amount

    Accurate Interpretation

    Developmentally
    Appropriate Response

    Awareness
    Of Feeding Cues

    Impaired Self-Regulation
    •Diminished satiation/satiety

    •Increased energy intake

    Impaired Self-Regulation
    •Diminished satiation/satiety

    •Increased energy intake

    Figure 1 Figure 1 presents a model for the pathway from discordant feeding

    responsiveness to accelerated weight gain and/or overweight. This model

    suggests that chronic mismatch between a caregiver’s responsiveness and an

    infant’s feeding cues can result in increased feedings (amount and/or

    frequency), which eventually lead to the acceleration of weight gain and

    overweight via impaired infant self-regulation. A caregiver’s responsiveness

    refers to both the amount and quality of responsive behaviors. The model

    illustrates that caregiver and infant relationship is reciprocal, which is

    impacted by the clarity of infant cues. The model also acknowledges that

    the caregiver–infant dyad exists within a socio-environmental context, which

    might impact the relationship.

    Responsive feeding and infant overweight
    KI DiSantis et al

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    International Journal of Obesity

    the concepts outlined in the conceptual model (Figure 1),

    including responsive feeding, self-regulation, feeding/

    hunger cues, as well as terms related to obesity, such as rapid

    weight gain. The phrases/terms in quotations were searched

    for the exact phrase/term, whereas the other terms were not

    put in quotations to allow for a variety of combination terms

    to be searched. All search terms that included the word ‘Infant’

    were repeated using the term ‘Child’ to ensure an extensive

    search of the infant population.

    Study selection and

    grading

    Article titles and their abstracts were briefly reviewed by the

    first author (KI DiSantis) using the selection criteria. Those

    that met and questionably met the inclusion/exclusion

    criteria were then thoroughly reviewed for eligibility by all

    the authors. Inclusion criteria included the following:

    original research, published in English, published up to

    September 2009, involving healthy full-term infants, aged

    0–24 months of child age, including infant feeding/eating

    and/or infant weight/growth outcomes, and oriented toward

    child overweight/rapid weight gain and/or obesity. Owing to

    concerns about socioeconomic and cultural consistency

    across studies, and the goal of focusing on overnutrition

    and obesity (as opposed to slow growth and malnutrition),

    exclusion criteria included research conducted in developing

    countries. In addition, given the focus on infant overweight

    and obesity, research that focused on growth faltering

    (organic or non-organic) or low birth weight was excluded.

    Although including growth faltering and malnutrition

    studies would increase the quantity of articles extracted,

    they likely would not have added to the content of this

    review as responsive feeding in these studies are investigated

    in relation to a very different set of outcomes, including

    promotion of energy intake and weight gain.

    The quality assessment phase measured the level of

    evidence provided by each included study and utilized the

    Oxford University Centre for Evidence Based Medicine

    (CEBM) levels of evidence system.52 This system was

    developed to be an advancement of the Canadian Task Force

    on the Periodic Health Examination grading system of 1979.

    The ‘level’ of evidence is graded, primarily based on the rigor

    of the study design (e.g., randomization in interventions),

    sampling (e.g., response rate), longitudinal versus cross-

    sectional, outcome assessment (e.g., negative assessment if

    outcome measure is imprecise) and the follow-up rate, with

    ‘1a’ being the highest and ‘5’ being the lowest level. Levels of

    evidence were independently assigned to the included

    papers by two of the study authors. A consensus approach

    was used to resolve discordant assessments, in which a third

    reviewer independently graded the article and discussion by

    all authors was used to assign a final rating.

    Results

    Systematic review results

    The results of the systematic review are detailed in Table 1

    and illustrated in Figure 2. The search of three databases with

    25 aforementioned keywords provided 1877 hits. Owing to

    the fact that these databases contain subscriptions to the

    same journals or indexes, it was not possible to derive a

    unique number of hits. After elimination of redundant

    abstracts, 82 unique abstracts were deemed appropriate for

    full-abstract review based on the first author’s brief review of

    article titles and abstracts. These abstracts were then

    thoroughly reviewed by all authors based on the a priori

    inclusion/exclusion criteria described above to determine

    whether they would be selected for final analysis. First, 14

    articles were excluded because they were not original

    research studies, performed research in a population other

    than infants of 0–24 months and/or the research was

    performed with regard to malnutrition/growth faltering

    (Figure 2). The 68 remaining articles were assessed to

    determine whether some aspect of infant/child obesity was

    directly measured (eating behavior, intake weight and/or

    growth) and whether caregiver-feeding practices/behaviors

    were assessed (Figure 2). A total of 29 articles were excluded

    because some aspect of infant overweight/obesity or infant

    eating/intake outcomes was not directly measured. In most

    of these excluded cases, feeding observations or other

    feeding measures were used as a tool to investigate general

    parental responsiveness or general infant–caregiver

    Table 1 Systematic review search results by search term

    Search terms Number

    of hits

    from three

    databases

    Abstracts

    selected for

    detailed

    review

    Abstracts

    selected

    as meeting

    criteria

    for CEBM

    grading

    Responsive feeding 6 5 0

    Caregiver feeding styles 6 2 0

    Rapid weight gain and eating 6 2 0

    Infant feeding and responsiveness 85 13 0

    Child feeding and responsiveness 43 0 0

    Self-regulation and eating 19 3 0

    Infant-feeding cue or infant-feeding cues 13 1 0

    Parent feeding styles 12 1 0

    Rapid weight gain and Feeding 24 3 1

    Feeding interactions 94 13 1

    Infant feeding practices 328 9 2

    Feeding and satiety response 7 2 1

    Infant and satiety response 8 4 0

    ‘Infant growth’ and overweight 107 2 0

    ‘Infant feeding’ and obesity 99 3 2

    Child and hunger cues 10 0 0

    Child and fullness cues 1 0 0

    Infant and hunger cues 20 2 0

    Infant and fullness cues 1 0 0

    Satiety cues and infant 12 2 1

    Satiety cues and child 3 0 0

    Internal cues and infant 26 1 0

    Internal cues and child 18 0 0

    Self-regulation and infant nutrition 41 5 1

    ‘Care for development’ and feeding 888 9 0

    Total 1877 82 9

    Abbreviation: CEBM, Oxford University Centre for Evidence Based Medicine.

    Responsive feeding and infant overweight
    KI DiSantis et al

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    International Journal of Obesity

    interaction, but the observations were never presented in the

    context of infant eating/intake outcomes or were not

    directed toward obesity outcomes child overweight/obesity.

    Overall, 30 articles were excluded because of lack of

    assessment of caregiver-feeding practices/behaviors, for

    instance, in which feeding characteristics and infant growth

    might have been assessed but no aspect of responsiveness

    was measured. After screening all abstracts, a total of nine

    articles met the inclusion/exclusion criteria and were

    included in the systematic review (Figure 2).

    The results of evidence-level grading for the nine articles,

    based on CEBM criteria, are provided in Table 2. All articles

    were graded as being a ‘2c’ level or lower level, meaning the

    design was cross-sectional or a lower quality cohort study or

    case–control study. Table 2 also provides additional details

    related to the quality of the research studies, including

    sampling characteristics, methods of measuring feeding

    responsiveness and a brief outcome summary. Below we

    briefly review these articles and their implications following

    the framework of the conceptual model in Figure 1.

    Narrative review

    Socioenvironmental context of discordant responsiveness. Feed-

    ing interactions take place within a wider social-environ-

    mental context, consisting of a wide range of factors like

    biobehavioral issues, culture, psychosocial status, physical

    environments and history at individual, family and com-

    munity level. Mogan53 was the only article in the review that

    considered context, by evaluating associations of both

    parental and infant weight status with maternal sensitivity

    to infant cues. Parental weight status is an individual-

    level

    variable, but in this study they accounted for the differences

    between dual and caregiver households with varying combi-

    nations of parents classified as normal or overweight.

    Parental weight status was categorized into three groups:

    (1) two normal weight parents, (2) one overweight and one

    normal and (3) two overweight parents. Mothers and infants

    were observed during six feeding sessions from age 0 to 6

    months to assess feeding interactions. The observations were

    coded using the Nursing

    Child Feeding Assessment Scale,

    which contained the following subscales: mother’s sensitiv-

    ity to cues, response to distress, social –and emotional

    growth fostering, cognitive fostering and the infant’s clarity

    of cues and responsiveness to their mother. This measure,

    particularly the mother’s sensitivity to cues and infant

    responsiveness subscales, allowed for the assessment of

    discordance in responsiveness in a bidirectional manner as

    presented in Figure 1. Although the methodology was

    strong, the authors did not find that these responsive

    feeding behaviors of the mother and/or infant differed

    among the parental weight groups. However, infant weight

    status differed significantly at 6 months of age according to

    parent weight group, with infants who had one or two

    overweight parents being more likely to be at or above the

    90th percentile for weight. Mogan53 did not report on

    relationships between maternal feeding responsiveness and

    infant weight status at 6 months, so it is unclear whether any

    relationship existed in this sample. Although this study used

    observational data, which assessed the bidirectional feeding

    relationship, it neither found relationship between parental

    weight status and responsive maternal–infant feeding inter-

    actions nor did it report on the association of responsive

    feeding with infant weight at 6 months. Other studies of

    older children have connected maternal weight status with

    unresponsive feeding practices (i.e., restriction in feeding),54

    but are outside the developmental scope of this review.

    Discordant responsiveness and feeding frequency and amount. As

    Figure 1 illustrates, discordant responsiveness in feeding

    might lead to increased feeding frequency or amount.

    Numerous circumstances of discordance could combine to

    result in increased feeding frequency (including feeding an

    infant in the absence of hunger cues, misperception of

    hunger cues) and increased amounts of food (including

    ignoring fullness cues, or misperception of fullness cues). If

    this were to continue over a period of time, the risk of

    increased energy would increase. Kavanagh et al.55 per-

    formed a double-blinded, randomized intervention, which

    focused on using education on feeding responsiveness and

    prevention of overfeeding to reduce the risk of overfeeding

    (infants were 3–10 weeks at enrollment). The control group

    82 studies identified for full abstract review

    4 excluded due to not being
    original research

    8 excluded due to sample being
    malnourished, premature, or
    having other health problem

    involved in eating and/or weight

    68 studies performed in samples
    with healthy infants 0-24

    months

    9 original research studies performed in samples
    with healthy infants 0-24 months with

    obesity

    outcomes and measuring and/or feeding and eating
    included in evidence-based systematic review

    78 studies original research

    76 studies performed in
    sample aged 0-24 months

    39 studies performed in samples
    with healthy infants 0-24 months

    with obesity outcomes

    29 excluded due to outcome not
    being a direct measurement of

    obesity

    30 excluded child eating or
    maternal feeding was not either

    predictor or outcome

    2 excluded due to sample age

    Figure 2 Flow diagram of article extraction.

    Responsive feeding and infant overweight
    KI DiSantis et al

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    Table 2 Systematic review results

    Article Design, setting and variables Sample

    characteristics

    Measure of responsiveness

    (type, description)

    Summary of results CEBM

    level

    assigned

    Social-environmental context of discordant responsiveness

    Mogan53 Design: prospective cohort

    Setting (country): US

    Independent variable(s)/intervention:

    Parents’ weight status (1 parent

    overweight, 2 parents overweight,

    2 parents normal weight)

    Outcome(s): parent–child

    interaction during six feedings

    from 0 to 6 months and infant

    weight status.

    n¼78 for feeding

    behavior

    analysis

    n¼62 for infant

    weight status

    analysis

    Age: 55–70 h

    Age(s) at

    follow-up:

    0–6 months

    Race/ethnicity:

    88.5% White,

    5.1% Asian, 2.6%

    East Indian, 1.3%

    Black and 2.6%

    other.

    Type: observational measure

    Description of measure: Nursing

    Child Feeding Assessment Scale,

    subscales: maternal sensitivity to

    cues, clarity of child cues, child’s

    responsiveness to parent during

    feeds.

    Feeding behaviors did not differ

    among the parental weight groups

    but a higher proportion of infants

    with two overweight parents

    had a growth percentile X90th

    percentile

    at

    6 months.

    2c

    Discordant responsiveness and increased feeding frequency/amount

    Kavanagh

    et al.55

    Design: double-blind, RCT

    Setting (country): US

    Independent variable(s)/intervention:

    educational intervention with

    general feeding guidelines and

    information on awareness of

    infant-satiety cues (single, 45-min

    session); Control participants

    received general feeding

    guidelines only.

    Outcome(s): formula intake

    (ml h�1; non-weighed, 2-day

    record) and weight gain.

    n¼61 at BSL

    n¼38 at follow-up

    Age: 3–10 weeks

    Age(s) at follow-

    up: 4–5 months

    Race/ethnicity: not

    reported.

    Type: Educational intervention

    Description of measure:

    intervention group received

    feeding responsiveness

    education, in addition to

    general infant-feeding

    guidelines.

    The intervention group did not

    differ significantly in formula intake

    or weight gain in the hypothesized

    direction, as the control group

    reported lower formula intake

    at 4–5 months and the intervention

    group had greater weight gain

    (grams per week).

    2b

    Discordant responsiveness and impaired self-regulation

    Rybski et al.56 Design: cross-sectional

    Setting (country): US

    Independent variable(s)/

    intervention: maternal behaviors

    during bottle feedings during six

    feedings over a 24-h periods

    Outcome(s): Infant-eating

    behaviors (total feeding time,

    sucking behaviors) and Infant

    energy intake (24-h weighed

    record).

    n¼10

    Age: 72 h

    Race/ethnicity:

    100% White.

    Type: Observational measure

    Description of measure:

    observed maternal behaviors

    during feedings (verbal

    interaction, eye contact,

    tender and caretaking

    touching).

    No association between the

    measured maternal feeding

    behaviors and either infant

    eating behaviors or 24-hour

    energy intake, but it is important

    to consider that mothers were

    not allowed to hold their infants

    during any feeds, which would

    clearly limit the amount of

    behaviors a mother can perform.

    4

    Discordant responsiveness and infant weight gain/overweight.

    Baughcuma

    et al.70 Design: cross-sectional

    Setting (country): US

    Independent variable(s)/intervention:

    child overweight (o90th percentile)

    and mother’s obese status

    (BMI X30)

    Outcome(s): infant-feeding

    styles.

    n¼453

    Age: 11–24

    months

    Race/ethnicity:

    77% non-Hispanic

    White, 16.6% non-

    Hispanic Black,

    1.4% Hispanic

    White and 5%

    others

    Type: Self-report survey

    Description of measure: Infant

    Feeding Styles Questionnaire

    (IFQ), subscales: Awareness of

    infant’s hunger and satiety

    cues, Feeding infant on

    schedule, using food to calm

    infant’s fussiness, social

    interaction with infant

    during feeding

    The IFQ subscales failed to associate

    responsive feeding behaviors to

    concurrent weight status of either

    infant (11–23 months) or mother.

    2c

    Dubois et al.69 Design: case–control

    Setting (country): Canada

    Independent variable(s)/intervention:

    Infant weight status (Obese cases

    (o90th percentile), normal controls

    (25th–75th percentile))

    Outcome(s): energy intake (3-day

    non-weighed, record) and

    maternal-feeding practices

    n¼89 (47 cases,

    42 controls)

    Age: 4–9 months

    Race/ethnicity: not

    reported.

    Type: qualitative self-report

    Description of measure:

    Open-ended questions on

    mother’s past feeding practices

    (e.g., breastfeeding) and

    mother’s concepts and

    attitudes toward infant

    feeding.

    Maternal responsiveness was an

    identified theme. Obese and control

    infants did not differ in the following

    maternal responsiveness to feeding,

    energy intake, or in her timing of

    breastfeeding cessation or

    supplementation introduction.

    3b

    Responsive feeding and infant overweight
    KI DiSantis et al

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    International Journal of Obesity

    (n¼ 21) received a 45-min educational session on general

    guidelines for infant feeding, including appropriate age of

    introduction of complementary foods, safe preparation of

    complementary foods, responsive feeding practices, when

    feeding complementary foods, and information on low-cost

    ways of providing nutritionally balanced meals. The inter-

    vention group (n¼19) was given similar information but

    additionally provided with educational information on

    being aware of infant-satiety cues when breastfeeding or

    bottle feeding (e.g., understanding early versus late cues) and

    were encouraged to only prepare 6 ounces of formula per

    feeding. The outcome measures were both infant weight and

    length and formula intake (measured at baseline, 2 weeks

    after the class and at about 4 months. Kavanagh et al.55

    found no differences between the intervention and control

    groups with regard to formula intake at any of the time

    points and bottle-emptying behavior, and conversely the

    intervention group infants were heavier and taller at 4

    months. Thus, this study did not provide support for the

    conceptual model. Kavanagh et al.55 acknowledged short-

    comings in this small study including that at baseline

    the intervention group infant’s were taller and heavier than

    the control group, the bottle records were not weighed

    and a considerable loss to follow-up rate with only 38%

    Table 2 (continued)

    Article Design, setting and variables Sample

    characteristics

    Measure of responsiveness

    (type, description)

    Summary of results CEBM

    level

    assigned

    Farrow and

    Blissett62

    Design: prospective cohort.

    Setting (country): UK

    Independent variable(s)/intervention:

    Maternal control in feeding

    at 6 months.

    Outcome(s): Infant growth

    (standardized to reference

    adjusting for age and gender)

    from birth to 6 months and from

    6 to 12 months.

    n¼69

    Age: 6 months

    Age(s) at

    follow-up:

    12 months

    Race/ethnicity: not

    reported.

    Type: observational

    Description of measure: Feeding

    Interaction Scale, a coding

    system for feeding observations

    measuring maternal control

    and infant autonomy.

    Maternal control moderated infant

    weight gain, with infants’ low

    control mothers regulating their

    growth from birth–12 months

    and infants’ high control mothers

    having poor growth regulation.

    Breast-fed infants had mothers

    that were less controlling

    than non-breastfed infants.

    2b

    Li et al.64 Design: -prospective cohort

    Setting (country): US

    Independent variable(s)/intervention:

    BF intensity (% all milk feedings

    that were breastmilk) and bottle–

    emptying behaviors (maternal

    self-report), at multiple time

    points from 1 to 6 months.

    Outcome(s): excess infant weight

    gain from 7 to 12 month old.

    n¼1896

    Age: B1 month

    Age(s) at follow-

    up: 2–12 mon

    Race/ethnicity:

    83.6% non-

    Hispanic White,

    6.9% non-Hispanic

    Black and 9.5%

    Hispanic.

    Type: Self-report survey

    Description of measure: survey

    of infant’s bottle use behavior

    (four 5-point Likert scale

    questions), focused on bottle

    emptying and mother’s

    encouragement to finish

    a bottle.

    High breastfeeding intensity resulted

    in significantly reduced excess weight

    gain. Infants who often emptied

    bottles in the first 6 months of life

    were 69% more likely to have excess

    weight gain in the second half of

    infancy, compared with those who

    rarely emptied bottles, but mother’s

    self-reported encouragement to

    empty bottles was not related to

    excess weight gain.

    2c

    Saxon et al.60 Design: retrospective cohort

    Setting (country): US

    Independent variable(s)/intervention:

    Infant weight, length, head

    circumference at birth, 2, 4- and

    6 months.

    Outcome(s): mother’s reported

    feeding practice from birth to

    9 months.

    n¼48

    Age: 12 months.

    Race/Ethnicity:

    81% White, 11%

    Hispanic, 3% black

    and 3% Asian.

    Type: Self-report survey

    Description of measure: feeding

    practices survey (14-items)

    focused on demand and

    scheduling feeding (e.g., who

    (mother or baby) determined

    when the baby ate; does

    mother recognize fussiness

    as a hunger cue).

    Feeding style (on-demand versus

    scheduled) was not associated with

    any growth variables across the first

    year of life. However, predicting

    growth changes based on current

    feeding styles might not capture

    the prospective effect of feeding

    on growth, as current feeding

    behaviors might have changed in

    response to infant growth changes.

    4

    Worobey et al.65 Design: prospective cohort.

    Setting (country): US

    Independent variable(s)/intervention:

    maternal sensitivity to infant-feeding

    cues and infant-feeding record

    (24-h recall) at 3 and 6 months.

    Outcome(s): Infant weight gain

    from birth–3 months, 3–6 months

    and 6–12 months.

    n¼96

    Age: newborn

    (enrolled at first

    WIC visit)

    Age(s) at

    follow-up: 3, 6

    and 12 months.

    Race/ethnicity:

    76% Hispanic and

    24% Black.

    Type: observational

    Description of measure:

    maternal sensitivity to cues

    subscale of the Nursing Child

    Feeding Assessment Scale.

    Infants gained more from 6 to 12

    months if their mothers were less

    sensitive to satiety cues. Also, infants

    whose mother’s reported a greater

    number of feeds per day had greater

    growth from 6 to 12 months.

    Growth between other time points

    were not significantly related to the

    feeding variables.

    3b

    Abbreviations: BMI, body mass index; BSL, baseline; BF, breastfeeding; CEBM, Oxford University Centre for Evidence Based Medicine; RCT, randomized control trial;

    UK, United Kingdom; US, United States; WIC, United States Special Nutritional Supplement Program for Women, Infants and Children. aNote: Two studies were

    presented within this article, but only the study performed within an infant sample was presented in this review.

    Responsive feeding and infant overweight
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    of the original sample completing both the class and the

    assessments.

    Rybski et al.56 similarly studied the associations between

    maternal feeding behaviors and infant intake, in a small

    sample of 3-day-old female, white infants. Although the

    study observed maternal behaviors related to responsiveness

    during bottle feedings (i.e., verbal interaction, eye contact,

    tender and caretaking touching), the purpose of the study

    was to observe changes in sucking behaviors and intake of

    formula across a 24-h period to understand the potential

    effects of circadian periodicity. The feeding variables (e.g.,

    total feeding time, nutritive sucking time nutritive sucking

    count) were measured during six observations set at the same

    time for all participants across a 24-h period in a stimuli-free

    room, with controlled temperature and lighting. This study

    did not find an association between maternal feeding

    behaviors and infant energy intake. A potential source of

    bias for evaluating feeding responsiveness was that mothers

    were not allowed to hold their infants during any feeds,

    which could have limited the amount and type of (e.g.,

    touching) behaviors a mother was engaged in during a

    feeding. In view of these shortcomings of these studies,

    additional research is needed to evaluate the effect of

    caregiver awareness of infant-feeding cues on infant energy

    intake and subsequent weight gain.

    Discordant responsiveness and impaired self-regulation. As

    shown in Figure 1, we suggest that caregiver feeding

    responses that are discordant with infant hunger and

    fullness cues could led to impaired satiety response in the

    infant. Experimental and observational studies have shown

    that infants and toddlers possess an ability to self-regulate

    energy intake at and across eating occasions by adjusting

    food intake in response to changes in feeding frequency and

    the energy content of foods consumed.57–59 Responsive

    caregiving is believed to promote cause (i.e., infant cue)

    and effect (i.e., caregiver response) learning that is central to

    the development of self-regulation.24 Some have suggested

    that chronically unresponsive feeding may negatively influ-

    ence what children learn about when eating should begin

    and end.40,41 This systematic review, however, did not

    identify any research that has evaluated the assertion that

    feeding interactions affect infant satiation. As such, there is

    currently no evidence to suggest that responsiveness influ-

    ences child self-regulation of energy intake in infancy or

    toddlerhood. The notion that feeding children in the

    absence of hunger and continuing to feed beyond fullness

    is detrimental to the development of self-regulation has

    appeared in scholarly writing for well over half a century.

    The findings of this review suggest the need for research

    explicitly measuring dimensions of appetite regulation,

    including hunger, satiety and satiation. Owing to a lack of

    studies and negative finding, evidence that feeding respon-

    siveness influences infant self-regulation of energy intake

    remains weak.

    Discordant responsiveness and accelerated weight gain and
    overweight

    Compared with other areas of the model, a relatively greater

    number of studies were identified involving the association

    of responsiveness to infant cues with infant weight status

    and weight gain. Saxon et al.60 studied maternal feeding

    behaviors and subsequent weight gain. The feeding beha-

    viors focused on in Saxon et al.,60 measured whether a

    mother reported using demand or schedule feeding in the

    first 6 months of life, rather than more directly assessing

    responsiveness as we have described. However, the authors

    describe demand feeding in the same manner as we have

    describe responsive feeding, in which the caregiver would

    initiate feeding in response to infant-hunger cues, rather

    than based on the external factor of time. Mothers retro-

    spectively self-reported their feeding practices from birth to

    6 months, and were then classified as demand or schedule

    feeders based on the answers to these two questions:

    (1) I would classify my feeding philosophy as: (answers:

    ‘Feeding on demand’ or ‘Feeding on a schedule’) and (2) Who

    would you say usually determined your baby’s eating routine?

    (answers: ‘Me (myself/caregiver)’ or ‘Baby’). They reported

    that feeding style did not significantly predict infant weight

    gain at 2, 4 and 6 months (controlling for birth weight).

    Although Saxon et al.60 findings do not support a relationship

    between maternal feeding style and infant’s future weight

    status as proposed in the model, a few shortcomings must be

    noted. Foremost, demand versus scheduled feeding does not

    explicitly capture ‘responsive feeding’ as we have defined it.

    Also breastfeeding was not controlled for during analyses,

    even though it has been linked to growth particularly in the

    first 2 years of life,61 and the two groups had differential levels

    of breastfeeding.60 Lastly, evaluating growth (i.e., change with

    time) may have been more informative than assessing weight

    at each time point controlling for birth weight.

    Farrow and Blissett62 examined a well-researched aspect of

    responsive feeding, maternal control and its moderating

    effects on infant weight gain in the first year of life. Relative

    to the other studies reviewed, the maternal behavior of

    interest was well aligned with the definition of ‘responsive

    feeding’ used here. Maternal control was measured through

    the systematic coding of feeding observations (using the

    Feeding Interaction Scale,63 in which the observer rates the

    mother on a 1–9 scale, with 1 equaling a very controlling

    caregiver (e.g., mother is continuously forcing the infant to

    eat) and 9 equaling not controlling (e.g., mother is allowing

    the infant autonomy to control his or her own feeding,

    although supervising the infant). Infant weight was mea-

    sured at 6 and 12 months (birth weight was taken from

    hospital records). They found that infant weight gain from

    birth to 6 months, and from 6 to 12 months were negatively

    correlated, indicating that infants appear to self-regulate

    their weight in the first year of lifeFhowever, this was only

    found in infants with low maternal control in feeding.

    Infants with high-maternal control in feeding had the

    opposite patternFweight gain from birth to 6 months and

    Responsive feeding and infant overweight
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    International Journal of Obesity

    from 6 to 12 months was positively correlated, so that a high

    weight gainer from birth to 6 months would continue on the

    path of high weight gain. This suggests that, although

    infants have the capability of self-regulation of energy intake

    and weight gain, there is an interaction with the environ-

    ment (caregiver feeding control) that can modify the

    expression of this potential. Farrow and Blissett’s62 work

    offers insight into the role of one aspect of responsive

    feeding (maternal control) and infant growth. The prospec-

    tive nature of the study along with rigorous measures helps

    to add support to the model proposed here.

    In a more recent investigation identified, Li et al.64

    reported on a population-based survey of US mothers, which

    investigated whether breastfeeding duration and frequency,

    and exclusiveness and bottle-emptying practices predicted

    excess infant weight gain in the interval between 6 and

    12 months. These feeding practices were self-reported at

    multiple time points from birth to 6 months. Findings

    revealed that infants who often emptied bottles in the first 6

    months of life were 69% more likely to have excess weight

    gain in the second-half of infancy (6–12 months), when

    compared with those who rarely emptied bottles.64 Also,

    high breastfeeding intensity (combination of duration and

    frequency) resulted in significantly reduced excess weight

    gain. This study explores the ‘what’ of infant feeding

    (breastmilk versus formula), which is often focused on with

    relation to obesity, but also explores the ‘how,’ through the

    effects of bottle emptying. These findings highlight

    behavioral aspects of infant feeding, which affected infant

    weight gain in this large sample (n¼1896). An issue in

    interpreting these findings is the extent to which bottle-

    emptying behaviors reflected infants’ appetites versus

    caregivers’ responsiveness to infant-feeding cues. Additional

    research is needed to address this issue.

    Worobey et al.65 assessed the association of infant growth

    with maternal-feeding attitudes related to responsiveness for

    their association with infant growth in a sample of low

    income, minority women and their newborn infants.

    Maternal ‘pushiness’ during feeding (using the Maternal

    Feeding Attitudes Questionnaire66) and maternal sensitivity

    to infant cues (using the Nursing Child Assessment Feeding

    Scale67,68) were assessed in relation to infant growth from

    birth to 12 months. After controlling for numerous factors

    (such as birth weight, gender, race/ethnicity, maternal age,

    maternal body mass index before pregnancy), infant weight

    gain between 6 and 12 months was predicted by mothers’

    sensitivity to satiety cues such that low-maternal sensitivity

    to infant cues resulted in increased weight gain. It should be

    noted that infant growth measures lacked standardization, as

    change in actual weight was investigated (i.e., weight gained

    from 6 to 12 months of age), no change in growth based on a

    standardized growth reference (i.e., weight-for-age Z-score

    change). As a result, the changes in growth only speak to

    change to one’s own baseline not in reference to whether the

    individual’s growth would trail, equal or exceed other

    individual’s of similar gender and age.

    Two studies were identified that assessed infant obesity/

    overweight in relationship with responsive feeding. Dubois

    et al.69 sampled two groups of infants; 42 normal weight 4–9

    months old (25–75th percentiles and 47 overweight 4–9

    months old (o90th percentile). They investigated whether

    these two groups differed in energy intake, infant feeding

    history and maternal reliance on external cues. For ‘maternal

    reliance on external cues’, mothers were asked open-ended

    questions and their answers were coded with respect to the

    following variables: mother usually uses external cues to

    initiate or terminate feedings, sometimes tries to feed more

    or less than the infant wants and sometimes offers food to

    stop infant’s crying. External cues were described as time or

    prepared portion of formula/food and infant signals were

    described as sucking fingers (hunger) or turning head away

    (fullness). Dubois et al.69 found no differences in maternal

    reliance on external cues among the groups of overweight

    4- to 9-month-old infants (o90th percentile) and normal

    infants (25–75th percentiles). However, the method of

    measuring maternal feeding responsiveness was not standar-

    dized as open-ended questions were used, which had not

    been previously validated. Baughcum et al.70 investigated the

    affect of maternal-feeding behaviors on weight in an infant

    sample (aged 11–23 months). A separate sample of pre-

    schoolers was assessed as part of this study;70 however, those

    results are not discussed given the focus of this review on

    infants and toddlers. Within the infant sample, a number of

    aspects of maternal feeding in which responsiveness is

    implicit were assessed for the association with infant weight

    status, including concern about the infant’s weight (either

    over- or underweight), concern about the infant being

    hungry, using food to calm the infant and establishing a

    feeding schedule. However, no associations were identified

    between a particular feeding style and overweight in infants.

    Income was found to influence feeding behaviors, for

    example low-income mothers of infants reported more

    concern about infant hunger and feeding infant on a

    schedule. Thus, the findings of Baughcum et al.70 did not

    add support for the model. But a criticism is that the purpose

    of the study was in part to validate the questionnaires

    usedFthese new questionnaires might have failed to

    elucidate responsive feeding behaviors. For example, mater-

    nal control in feeding, commonly measured through the

    validated Child Feeding Questionnaire,71 has previously

    been connected with child overweight,72,73 yet in this study,

    control was not associated with child overweight. Also

    measuring concurrent weight and feeding behaviors might

    not reflect any of the effects from feeding behaviors in

    infancy on later childhood overweight. Most of the evidence

    was gathered to support the connection between responsive

    feeding and weight gain/overweight as presented in the

    model, and of the six studies identified, three added support.

    Summary of the systematic review findings

    The evidence gathered was rated at 2b or lower level of the

    CEBM system, meaning there was a dearth of high-quality

    Responsive feeding and infant overweight
    KI DiSantis et al

    488

    International Journal of Obesity

    prospective work. Of the nine studies described here, only

    three studies (Farrow and Blissett62; Li et al.64; Worobey

    et al.65) revealed associations with dimensions of feeding

    responsiveness as described for the model. Although these

    studies provide preliminary support for an influence of

    responsive feeding on infant/toddler weight, there was a

    notable lack of evidence to substantiate the assertion that

    such a relationship is produced by excessive energy intake.

    Further, the methods for measuring responsive feeding as

    reviewed in this narrative and as presented in Table 2,

    generally reveal a lack of consistency in the manner in which

    feeding responsiveness has been operationally defined. This

    concern, along with the failure to consider the bidirectional

    nature of maternal responsiveness and infant behaviors,

    points to the need for further exploration.

    Discussion

    This systematic review offered the opportunity to describe

    the rationale for investigating responsive feeding and over-

    weight during infancy and toddlerhood and to assess the

    state of the science on this topic. The conceptual model

    provided a framework for identifying and thematically

    organizing scientific literature on this topic. The systematic

    approach adopted here revealed a dearth of rigorous inquiry

    on this topic. The three studies that provided the strongest

    support for the model (Farrow and Blissett62; Li et al.64;

    Worobey et al.65) evaluated maternal responses to satiety

    cues and/or bottle-emptying behaviors and their association

    with infant growth. Only Li et al.,64 however, assessed

    feeding interactions in a longitudinal manner. In general,

    all the articles retrieved, supportive or not, lacked prospec-

    tive assessments of infant–caregiver interactions as they

    relate to self-regulation, growth and obesity, which was

    evidenced by the relatively low CEBM levels assigned to the

    studies gathered. This is a crucial gap in the current literature

    in light of recognition that feeding interactions are nested in

    developmental phases. So that capturing caregiver–infant

    interactions at one time point only provides insight into that

    point in development. That there was a shortage of support

    for the proposed model from the primarily cross-sectional

    studies in this systematic review should not discourage

    further inquiry.

    Beyond the dearth of longitudinal work in this area, the

    assessment of the dynamic nature of caregiver–infant

    feeding interactions is notably lacking. Responsiveness can

    be conceived of as a reciprocal dimension of feeding in

    which children are responsible for providing clear feeding

    cues and the caregiver for responding in a prompt and

    developmentally appropriate manner. However, rather than

    focusing on how bidirectional aspects of feeding relate with

    obesity outcomes (increased energy intake, rapid weight gain

    overweight), studies have focused on how infant-eating

    behaviors or caregiver (primarily maternal)-feeding

    behaviors independently affect these outcomes. This is

    potentially because of the lack of assessment tools, which

    measure interactions in a dynamic manner, rather than

    assessing the infant or the caregiver alone. To move knowl-

    edge ahead in the area of feeding behaviors and obesity

    prevention, it is necessary to begin to assess the dyad. Such

    assessments would aid in evaluating the usefulness of the

    proposed model.

    In addition to the alternating focus on either infant or

    caregiver behaviors, there was a noteworthy lack of consis-

    tency in measurement of ‘responsive feeding.’ The variation

    in measurement is illustrated by the variety of constructs

    reported on by the articles in this review (Table 2). Variables

    used to represent responsive feeding included demand/

    schedule feeding,60 bottle emptying,64 observational mea-

    sures (e.g., NCAST)56 and self-report measures of caregiver

    behaviors.62,70 An additional complicating factor is that

    previous research in responsive feeding has been largely

    oriented toward undernutrition and has conceptualized

    feeding responsiveness more broadly than is considered here

    for obesity prevention. Measuring responsive feeding in the

    framework of obesity prevention may require a different

    operational definition of responsive feeding than those used

    in the context of undernutrition. In the model explored

    here, discordant responsiveness leads to increases in infant

    intake, which could lead to chronic energy imbalance and,

    eventually, overweight. The relatively new interest in

    viewing responsive feeding in the context of child obesity

    risk may explain the lack of concerted study on this topic.

    Why has feeding responsiveness been largely ignored in

    efforts to understand the development of overweight?

    Exploration of feeding dynamics and their role in intake

    and growth requires a multidisciplinary perspective invol-

    ving parenting, pediatric nutrition and child development.

    Psychologists have long studied feeding, but viewed it

    primarily as a vehicle for studying parent–child relationships

    and developmental outcomes other than growth rather than

    as phenomena of interest unto itself. Nutritionists have

    historically viewed children’s eating behavior in terms of

    food and nutrient intake rather than feeding and eating

    behavior. As a result most knowledge related to feeding

    pertains to what children are fed rather than how children

    are fed. Recognition of environmental contributions to

    pediatric overweight and challenges to its treatment have

    only recently directed scholarly interest toward understand-

    ing familial influences on the development of eating

    behavior.

    Acknowledging that the caregiver–infant dyad and family

    is situated within a broader socioenvironment context

    encompassing among others, cultural beliefs/practices about

    parenting and feeding, policy, education, healthcare and

    childcare, it is clear that a great deal of work remains to be

    carried out to begin to understand the complexities of

    interactions among these factors and the intrapersonal and

    interpersonal factors we think shape dyadic feeding inter-

    actions. It is overwhelming and beyond the scope of any

    Responsive feeding and infant overweight
    KI DiSantis et al

    489

    International Journal of Obesity

    single study to undertake such a task, but such a broad

    conceptual model as proposed here is useful to the field at

    large, pointing to particular relationships that are un- or

    underexplored and highlighting areas in which interdisci-

    plinary collaborations could be fruitful. As first steps in

    advancing knowledge in this area, we offer some suggestions.

    The development of well-operationalized and rigorously

    developed measurement tools is clearly a priority for moving

    scientific inquiry forward in this area. Rigorous observational

    approaches should be considered in initial research efforts to

    characterize feeding responsiveness and to identify dimen-

    sions for which self-report may be possible.74 Qualitative

    methods may also prove fruitful to identify potential

    facilitators and barriers to responsiveness, such as caregiver

    feeding knowledge, attitudes and beliefs. Longitudinal

    studies will be required to draw inferences about the capacity

    of responsiveness to modify child nutritional and growth

    trajectories. Beyond closing in on the caregiver–child inter-

    actions, a multidisciplinary approach must be taken to

    address the complexity of both caregiver–infant interactions

    and obesity and how and whether responsive feeding relates

    to the entire growth spectrum (undernutrition to obesity).

    Points of exploration, include experiences of the infant and

    caregiver during feeding from mood and stress,75,76 altera-

    tions in neurohormones77 and racial/ethnic differences and

    cultural beliefs, which might alter caregivers’ attitude to

    optimal responsiveness, can be investigated.78,79 Thus,

    efforts to understand the development of infant/child eating

    behavior and its importance for growth should take feeding,

    its goals and its context into consideration. The dependence

    of infants and toddlers on their caregivers to obtain nutrition

    and develop eating skills suggests a potentially critical role

    for responsive feeding in nutrition and growth from a very

    early point in development. A recent study of overweight

    children illustrates the need for such early interventions, as

    it found that nearly 60% of overweight children became

    overweight before the age of 2 years.3 As a potentially

    modifiable behavior, responsiveness may represent an

    efficacious target for early obesity prevention efforts in the

    future.

    Conclusion

    In conclusion, the notion that a chronic mismatch between

    feeding and child cues contributes to the development of

    overweight is not new.29,41 On the basis of the findings of

    this systematic review, however, the role of feeding respon-

    siveness in accelerated growth and overweight remains, to

    date, is more speculative than substantive. There is pre-

    liminary support for the proposed role of responsiveness in

    growth during early development, though the strength of

    evidence is relatively weak and the studies are few. These

    findings underscore that we are in the early stage of

    empirical research on this topic. As such, we conclude that

    additional rigorous investigation of feeding responsiveness is

    needed, particularly longitudinal studies, within the frame-

    work of early obesity prevention efforts among diverse

    populations.

    Conflict of interest

    The authors declare no conflict of interest.

    Acknowledgements

    This work was supported by the NIH K01 DK 61319-01

    (Fisher), USDA 2005-55215-6 16726 (Johnson), NIH DK

    56350 (Hodges), RWJF 66523 (Hodges) and Nestle Infant

    Nutrition (Fisher).

    References

    1 Kral TV, Stunkard AJ, Berkowitz RI, Stallings VA, Brown DD, Faith
    MS. Daily food intake in relation to dietary energy density in the
    free-living environment: a prospective analysis of children born
    at different risk of obesity. Am J Clin Nutr 2007; 86: 41–47.

    2 Stettler N, Iotova V. Early growth patterns and long-term obesity
    risk. Curr Opin Clin Nutr 2010; 13: 294–299.

    3 Harrington JW, Nguyen VQ, Paulson JF, Garland R, Pasquinelli L,
    Lewis D. Identifying the ‘tipping point’ age for overweight
    pediatric patients. Clin Pediatr (Phila) 2010; 49: 638–643.

    4 Stettler N, Kumanyika SK, Katz SH, Zemel BS, Stallings VA. Rapid
    weight gain during infancy and obesity in young adulthood in a
    cohort of African Americans. Am J Clin Nutr 2003; 77: 1374–1378.

    5 Monteiro POA, Victora CG. Rapid growth in infancy and
    childhood and obesity in later lifeFa systematic review. Obesity
    Rev 2005; 6: 143–154.

    6 Wells JC, Chomtho S, Fewtrell MS. Programming of body
    composition by early growth and nutrition. Proc Nutr Soc 2007;
    66: 423–434.

    7 Shonkoff JP, Phillips De. From Neurons to Neighborhoods: the Science
    of Early Childhood Development. National Academy Press:
    Washington, DC, 2000.

    8 Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegal KM.
    Prevalence of high body mass index in US children and
    adolescents, 2007–2008. JAMA 2010; 303: 242–249.

    9 Scaglioni S, Agostoni C, Notaris RD, Radaelli G, Radice N,
    Valenti M. et al. Early macronutrient intake and overweight at
    five years of age. Int J Obes Relat Metab Disord 2000; 24: 777–781.

    10 Mellbin T, Vuille JC. Relationship of weight gain in infancy to
    subcutaneous fat and relative weight at 10 1/2 years of age. Br J
    Prev Soc Med 1976; 30: 239–243.

    11 Mei Z, Grummer-Strawn LM, Scanlon KS. Does overweight in
    infancy persist through the preschool years? An analysis of CDC
    Pediatric Nutrition Surveillance System data. Soz Praventivmed
    2003; 48: 161–167.

    12 Stettler N, Zemel BS, Kumanyika S, Stallings VA. Infant weight
    gain and childhood overweight status in a multicenter, cohort
    study. Pedatrics 2002; 109: 194–199.

    13 Reilly JJ, Armstrong J, Dorosty AR, Emmett PM, Ness A, Rogers I
    et al. Early life risk factors for obesity in childhood: cohort study.
    BMJ 2005; 330: 1357.

    14 Dennison BA, Edmunds LS, Stratton HH, Pruzek RM. Rapid infant
    weight gain predicts childhood overweight. Obesity 2006; 14:
    491–499.

    Responsive feeding and infant overweight
    KI DiSantis et al

    490

    International Journal of Obesity

    15 Dubois L, Girard M. Early determinants of overweight at 4.5 years in
    a population-based longitudinal study. Int J Obes 2006; 30: 610–617.

    16 Karaolis-Danckert N, Buyken AE, Bolzenius K, Perim de Faria C,
    Lentze MJ, Kroke A. Rapid growth among term children whose
    birth weight was appropriate for gestational age has a longer
    lasting effect on body fat percentage than on body mass index.
    Am J Clin Nutr 2006; 84: 1449–1455.

    17 Blair NJ, Thompson JMD, Black PN, Becroft DMO, Clark PM,
    Han DY et al. Risk factors for obesity in 7-year-old European
    children: the Auckland Birthweight Collaborative Study. Arch Dis
    Child 2007; 92: 866–871.

    18 Stettler N, Kumanyika S, Katz SH, Zemel BS, Stallings VA. Rapid
    early infancy weight gain and obesity in African American adults.
    Circulation 2003; 107: E7002.

    19 Stettler N, Stallings VA, Troxel AB, Zhao J, Schinnar R, Nelson SE
    et al. Weight gain in the first week of life and overweight in
    adulthood: a cohort study of European American subjects fed
    infant formula. Circulation 2005; 111: 1897–1903.

    20 Monteiro POA, Victora CG, Barros FC, Monteiro LMA. Birth size,
    early childhood growth, and adolescent obesity in a Brazilian
    birth cohort. Int J Obes 2003; 27: 1274–1282.

    21 Ekelund U, Ong K, Linne Y, Neovius M, Brage S, Dunger DB et al.
    Upward weight percentile crossing in infancy and early child-
    hood independently predicts fat mass in young adults: the
    Stockholm Weight Development Study (SWEDES). Am J Clin Nutr
    2006; 83: 324–330.

    22 Stettler N, Iotova V. Early growth patterns and long-term obesity
    risk. Curr Opin Clin Nutr Metab Care 2010; 13: 294–299.

    23 Ong KK, Emmett PM, Noble S, Ness A, Dunger DB, Team AS.
    Dietary energy intake at the age of 4 months predicts postnatal
    weight gain and childhood body mass index. Pedatrics 2006; 117:
    e503–e508.

    24 Lamb ME, Easterbrooks MA. Individual differences in parental
    sensitivity: origins, components, and consequences. In: Lamb
    ME, Sherrod LR, (eds). Infant Social Cognition: Empirical and
    Theoretical Considerations. Erlbaum: Hillsdale, NJ, 1981; 127–153.

    25 Ziv Y, Cassidy J. Maternal responsiveness to infant irritability: the
    contribution of Crockenberg and Smith’s ‘Antecedents of
    mother-infant interaction and infant irritability in the first
    3 months of life’. Infant Behav Dev 2002; 25: 16–20.

    26 Feldman R, Greenbaum CW, Yirmiya N. Mother-infant affect
    synchrony as an antecedent of the emergence of self-control.
    Dev Psychol 1999; 35: 223–231.

    27 Bronson MB. Self-regulation in Early Childhood: Nature and Nurture.
    The Guilford Press: New York, NY, 2000.

    28 Green JA, Gustafson GE, Irwin JR, Kalinowski LL, Wood RM.
    Infant crying: acoustics, perception, and communication. Early
    Dev Parenting 1995; 4: 161–175.

    29 Ainsworth MDS, Bell SM. Some Contemporary Patterns of Mother-
    infant Interaction in the Feeding Situation Stimulation in Early
    Infancy. Academic Press: New York, 1969.

    30 Bell SM, Ainsworth MD. Infant crying and maternal responsive-
    ness. Child Dev 1972; 43: 1171–1190.

    31 Bornstein MH, Tamis-LeMonda CS. Maternal responsiveness and
    cognitive development in children. New Dir Child Dev 1989;
    1989: 49–61.

    32 Goldberg S. Social competence in infancy: a model of parent–
    infant interaction. Merrill-Palmer Quart 1977; 23: 163–177.

    33 Vallotton CD. Do infants influence their quality of care? Infants’
    communicative gestures predict caregivers’ responsiveness. Infant
    Behav Dev 2009; 32: 351–365.

    34 Wright P, Fawcett J, Crow R. The development of differences in
    the feeding behaviour of bottle and breast fed human infants
    from birth to two months. Behav Process 1980; 5: 1–20.

    35 Wright P. Development of feeding behavior in early infancy:
    implications for obesity. Health Bull 1981; 39: 197–205.

    36 Fomon SJ, Filer LJ, Thomas LN, Rogers RR, Proksch AM.
    Relationship between formula concentration and rate of growth
    of normal infants. J Nutr 1969; 98: 241–254.

    37 Fomon SJ, Filmer LJ, Thomas LN, Anderson TA, Nelson SE.
    Influence of formula concentration on caloric intake and growth
    of normal infants. Acta Paediatric Scandinavia 1975; 64: 172–181.

    38 Kent JC, Mitoulas LR, Cregan MD, Ramsay DT, Doherty DA,
    Hartmann PE. Volume and frequency of breastfeedings and fat
    content of breast milk throughout the day. Pedatrics 2006; 117:
    e387–e395.

    39 Fox MK, Devaney B, Reidy K, Razafindrakoto C, Ziegler P.
    Relationship between portion size and energy intake among
    infants and toddlers: evidence of self-regulation. J Am Diet Assoc
    2006; 106 (1S): 77–83.

    40 Wright P. Learning experiences in feeding behaviour during
    infancy. J Psychosom Res 1988; 32: 613–619.

    41 Costanzo PR, Woody EZ. Domain-specific parenting styles and
    their impact on the child’s development of a particular deviance:
    the example of obesity proneness. J Soc Clin Psychol 1985; 4:
    425–445.

    42 Bruch H. Eating Disorders: Obesity, Anorexia Nervosa, and the Person
    Within. Basic Books: New York, 1973.

    43 Birch LL, Fisher JO. Development of eating behaviors among
    children and adolescents. Pediatrics 1998; 101: 539–549.

    44 Engle PL, Bentley ME, Pelto G. The role of care in nutrition
    programmes:current research a research agenda. Proc Nutr Soc
    2000; 59: 25–35.

    45 Bornstein MH. Sensitive periods in development: structural
    characteristics and causal interpretations. Psychol Bull 1989;
    105: 179–197.

    46 Dewey K. Guiding principles for complementary feeding of the breastfed
    child. PAHO/WHO: Washington, DC, 2003. http://www.who.int/
    nutrition/publications/guiding_principles_compfeeding_breastfed .

    47 Bronfenbrenner U. Ecology of the family as a context for human
    development: research perspectives. Dev Psychol 1986; 22: 723–742.

    48 Taveras EM, Gillman MW, Kleinman K, Rich-Edwards JW, Rifas-
    Shiman SL. Racial/ethnic differences in early-life risk factors for
    childhood obesity. Pediatrics 2010; 125: 686–695.

    49 World Health Organization U. Global Strategy for Infant and Young
    Child Feeding. WHO: Geneva, 2003.

    50 Burdette HL, Whitaker RC, Hall WC, Daniels SR. Maternal infant-
    feeding style and children’s adiposity at 5 years of age. Arch
    Pediatr Adolesc Med 2006; 160: 513–520.

    51 Susin LR, Giugliani ER, Kummer SC, Maciel M, Simon C,
    da Silveira LC. Does parental breastfeeding knowledge increase
    breastfeeding rates? Birth 1999; 26: 149–156.

    52 Centre for Evidence-Based Medicine OU. Levels of evidence and
    grades of recommendation. Available at: http://www.cebm.net/
    levels_of_evidence.asp. (Accessed 9 January 2009) 2009.

    53 Mogan J. Parental weight and its relation to infant feeding
    patterns and infant obesity. Int J Nurs Stud 1986; 23: 255–264.

    54 Francis LA, Birch LL. Maternal weight status modulates the effects
    of restriction on daughters’ eating and weight. Int J Obes Relat
    Metab Disord 2005; 29: 942–949.

    55 Kavanagh KF, Cohen RJ, Heinig MJ, Dewey KG. Educational
    intervention to modify bottle-feeding behaviors among formula-
    feeding mothers in the WIC program: impact on infant formula
    intake and weight gain. J Nutr Educ Behav 2008; 40: 244–250.

    56 Rybski DA, Almli CR, Gisel EG, Powers J, Maurer Jr M. Sucking
    behaviors of normal 3-day-old female neonates during a 24-h
    period. Dev Psychobiol 1984; 17: 79–86.

    57 Birch LL, Deysher M. Caloric compensation and sensory specific
    satiety: Evidence for self regulation of food intake by young
    children. Appetite 1986; 7: 323–331.

    58 Birch LL, Deysher M. Conditioned and unconditioned caloric
    compensation: evidence for self-regulation of food intake by
    young children. Learn Motiv 1985; 16: 341–355.

    59 Fomon S. Nutrition of Normal Infants. Mosby-Year Books: St Louis,
    Missouri, 1993.

    60 Saxon TF, Gollapalli A, Mitchell MW, Stanko S. Demand feeding
    or schedule feeding: infant growth from birth to 6 months.
    J Reprod Infant Psychol 2002; 20: 89–100.

    Responsive feeding and infant overweight
    KI DiSantis et al

    491

    International Journal of Obesity

    http://www.cebm.net/levels_of_evidence.asp

    http://www.cebm.net/levels_of_evidence.asp

    61 Kalies H, Heinrich J, Borte N, Schaaf B, von Berg A, von Kries R
    et al. The effect of breastfeeding on weight gain in infants: results
    of a birth cohort study. Eur J Med Res 2005; 10: 36–42.

    62 Farrow C, Blissett J. Does maternal control during feeding
    moderate early infant weight gain? Pediatrics 2006; 118: e293–e298.

    63 Wolke D, Skuse D. The management of infant feeding problems.
    In: Cooper P, Stein A (eds). Feeding Problems and Eating Disorders in
    Children and Adolescents. Harwood: Chur, Switzerland, 1992; 27–
    59.

    64 Li R, Fein SB, Grummer-Strawn LM. Association of breastfeeding
    intensity and bottle-emptying behaviors at early infancy with
    infants’ risk for excess weight at late infancy. Pediatrics 2008;
    122 (Suppl 2): S77–S84.

    65 Worobey J, Lopez MI, Hoffman DJ. Maternal behavior and infant
    weight gain in the first year. J Nutr Educ Behav 2009; 41: 169–175.

    66 Kramer MS, Barr RG, Leduc DG, Boisjoly C, Pless IB. Maternal
    psychological determinants of infant obesity. Development and
    testing of two new instruments. J Chronic Dis 1983; 36: 329–335.

    67 Barnard K. Caregiver/Parent-child Interaction Feeding Manual. Uni-
    versity of Washington School of Nursing: Seattle, WA, 1994.
    NCAST Publications.

    68 Hodges EA, Houck GM, Kindermann T. Reliability of the Nursing
    Child Assessment Feeding Scale during toddlerhood. Issues Compr
    Pediatr Nurs 2007; 30: 109–130.

    69 Dubois S, Hill DE, Beaton GH. An examination of factors believed
    to be associated with infantile obesity. Am J Clin Nutr 1979; 32:
    1997–2004.

    70 Baughcum AE, Powers SW, Johnson SB, Chamberlin LA, Deeks
    CM, Jain A et al. Maternal feeding practices and beliefs and their
    relationship to overweight in early childhood. J Dev Behav Pediatr
    2001; 22: 391–408.

    71 Birch LL, Fisher JO, Castro CN, Grimm-Thomas K, Sawyer R,
    Johnson SL. Confirmatory factor analysis of the Child Feeding
    Questionnaire: a measure of parental attitudes, beliefs and
    practices about child feeding and obesity proneness. Appetite
    2001; 36: 201–210.

    72 Faith MS, Scanlon KS, Birch LL, Francis LA, Sherry B. Parent-child
    feeding strategies and their relationships to child eating and
    weight status. Obes Res 2004; 12: 1711–1722.

    73 Spruijt-Metz D, Lindquist CH, Birch LL, Fisher JO, Goran MI.
    Relation between mothers’ child-feeding practices and children’s
    adiposity. Am J Clin Nutr 2002; 75: 581–586.

    74 Sacco LM, Bentley ME, Carby-Shields K, Borja JB, Goldman BD.
    Assessment of infant feeding styles among low-income African-
    American mothers: comparing reported and observed behaviors.
    Appetite 2007; 49: 131–140.

    75 Groer MW. Differences between exclusive breastfeeders, formula-
    feeders, and controls: a study of stress, mood, and endocrine
    variables. Biol Res Nurs 2005; 7: 106–117.

    76 Farrow CV, Blissett JM. Is maternal psychopathology related
    to obesigenic feeding practices at 1 year? Obes Res 2005; 13:
    1999–2005.

    77 Swain JE, Lorberbaum JP, Kose S, Strathearn L. Brain basis of early
    parent-infant interactions: psychology, physiology, and in vivo
    functional neuroimaging studies. J Child Psychol Psychiatry 2007;
    48: 262–287.

    78 Kumanyika SK. Environmental influences on childhood obesity:
    ethnic and cultural influences in context. Physiol Behav 2008; 94:
    61–70.

    79 Taveras EM, Gillman MW, Kleinman K, Rich-Edwards JW,
    Rifas-Shiman SL. Racial/ethnic differences in early-life risk factors
    for childhood obesity. Pediatrics 2010; 125: 686–695.

    Responsive feeding and infant overweight
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    Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

    • c.ijo20113a
    • The role of responsive feeding in overweight during infancy and toddlerhood: a systematic review

      Introduction

      Overweight and accelerated weight gain in infancy and toddlerhood

      Caregiving and self-regulation among infants and toddlers

      A potential role for responsive feeding

      Materials and methods

      Literature-search strategy

      Figure 1 Figure 1 presents a model for the pathway from discordant feeding responsiveness to accelerated weight gain and/or overweight.

      Study selection and grading

      Results

      Systematic review results

      Table 1 Systematic review search results by search term

      Narrative review

      Socioenvironmental context of discordant responsiveness

      Discordant responsiveness and feeding frequency and amount

      Figure 2 Flow diagram of article extraction.

      Table 2 Systematic review results

      Outline placeholder

      Discordant responsiveness and impaired self-regulation

      Discordant responsiveness and accelerated weight gain and overweight

      Summary of the systematic review findings

      Discussion

      Conclusion

      Conflict of interest

      Acknowledgements

      References

    _______________________________________________________________

    _______________________________________________________________
    Report Information from ProQuest
    February 10 2015 14:37
    _______________________________________________________________

    10 February 2015 ProQuest

    Table of contents

    1.

  • Child-care usage and mother-infant “quality time”
  • …………………………………………………………………………… 1

    10 February 2015 ii ProQuest

    Document 1 of 1

    Child-care usage and mother-infant “quality time”
    Author: Booth, Cathryn L; Clarke-Stewart, K Alison; Deborah Lowe Vandell; McCartney, Kathleen; Margaret
    Tresch Owen
    ProQuest document link
    Abstract: Mothers’ time-use paterns were compared in families in which infants spent more than 30 hours per
    week in child care (In-Care group; n = 143) versus 0 hours per week (At-Home group; n = 183) from birth to 6
    months of age. In-Care group mothers spend about 12 fewere hours per week interacting with their infants, for
    about 32% less time; fathers of these infants were more involved in caregiving.
    Full text: Headnote
    Mothers’ time-use patterns were compared in families in which infants spent more than 30 hours per week in
    child care (In-Care group; n = 143) versus 0 hours per week (At-Home group; n = 183) from birth to 6 months of
    age. In-Care group mothers spent about 12 fewer hours per week interacting with their infants, for about 32%
    less time; fathers of these infants were more involved in caregiving. The groups did not differ in the quality of
    mother-infant interaction. In the In-Care group, quantity of in
    Headnote
    teraction was related to greater separation anxiety and concerns about effects of maternal employment. Time-
    use data were not related to child outcomes at 15 months of age. Results suggest that the effect of extensive
    time spent apart on the quantity and quality of mother-infant interaction may be smaller than anticipated.
    Headnote
    Key Words: child care, mother-infant interaction, time use.
    Dramatic increases in the labor force participation of women with young children in the United States have led
    to a concomitant increase in the use of early and extensive nonmaternal child care, usually beginning in the
    early months of life (Hofferth, Brayfield, Deich, &Holcomb, 1991). The increasing use of extensive child care in
    early infancy has generated scientific debate about the effects of child care on children’s development and the
    mother-child relationship (see Lamb, 1998). One of the chief concerns is that early entry into child care may
    have a negative impact on the ability of the mother and infant to develop a synchronous relationship. That is,
    long hours spent apart may provide insufficient time for the mother to learn about her infant’s cues and
    biological rhythms (Brazelton, 1986), and her appropriate and sensitive responses to these cues are vital for
    fostering the infant’s optimal development (see Kelly &Barnard, 2000).
    A particular area of concern is the infant’s attachment security to the mother. According to attachment theory,
    the degree of mother-infant sensitivity and responsivity forms the basis for the development of the infant’s
    secure (or insecure) attachment to her (see De Wolff &van Ijzendoorn, 1997). The security of this attachment, in
    turn, is important because it predicts children’s subsequent peer relations, affect regulation, selfesteem, ego
    resiliency, and behavior problems (see Thompson, 1998). Thus, to the extent that maternal sensitivity and
    responsivity decrease when the mother and infant spend long hours apart, then we would expect an increase in
    the risk of insecure attachment and other less optimal outcomes.
    Infants form important and independent attachments to their fathers and other caregivers as well. However, a
    comparison of the relative influence of infant-mother and infant-father attachment on child outcomes has
    indicated that the infant-mother relationship is a stronger predictor (Thompson, 1998). These results, coupled
    with concerns about the effects on children of large increases in maternal employment hours, have led to a
    focus on the early mother-child, rather than father-child, relationship within the child-care and employment
    literature.
    Within the child-care literature, several studies focusing on early infancy have supported the hypothesis of a

    10 February 2015 Page 1 of 12 ProQuest

    http://nclive.org/cgi-bin/nclsm?url=http://search.proquest.com/docview/219764964?accountid=11330

    negative association between the amount of child care and the quality of motherinfant interaction, but the
    majority of researchers have not (see National Institute of Child Health and Human Development Early Child
    Care Research Network [NICHD ECCRN], 1999, for a review). Analyses from the NICHD Study of Early Child
    Care are especially relevant in this regard, because a subset of these data were used in the present report.
    Longitudinal analyses of the main data set indicated that greater hours per week in child care were related to
    somewhat less maternal sensitivity and child engagement in mother-child interaction in the first 3 years of life
    (NICHD ECCRN, 1999). However, this relatively small decrease in the quality of mother-child interaction did not
    appear to have an impact on the infants’ attachment security to their mothers, except when mothers were highly
    insensitive (NICHD ECCRN, 1997).
    In all of these studies, the quality of motherchild interaction and attachment security have been evaluated in
    relation to the number of hours that the child spends in child care or the number of hours that the mother is
    employed. However, it is significant that none of them has assessed the amount of time that the mother and
    child actually spend together, and in the absence of empirical evidence, it is generally assumed that hours of
    maternal employment serve as a proxy for the reduction in the amount of time spent in motherchild interaction
    (Baydar, Greek, &Gritz, 1999). Contrary to this assumption, evidence from studies based on time-use diaries
    and interviews has shown that maternal employment is related to a relatively small reduction in social
    interaction and a larger reduction in physical care (Baydar et al., 1999; Hilton, 1990; Nock &Kingston, 1988;
    Walker &Woods, 1976), with differences of less than 5 hours of care per week between employed and
    nonemployed mothers (Douthitt, 1989; Sanik, 1990).
    One limitation of these time-use studies is the assumption that time spent in mother-child interaction is, by
    definition, “quality time” that will enhance children’s development (Bryant, 1992). However, large individual
    differences exist in the quality of interaction when mothers and children do spend time together, and these
    differences predict child outcomes in cognitive, linguistic, and socioemotional domains (e.g., Baumrind, 1989;
    NICHD ECCRN, in press). Thus, it is important to measure directly the quality and quantity of mother-child
    interaction.
    It is also likely that there are individual differences in the extent to which mothers, regardless of employment
    hours, optimize the time that is available for interacting with their infants. In some families, employed mothers
    may make special efforts to spend high-quality time with their infants during nonwork hours or on the weekends,
    whereas in other families, the stresses of multiple roles and responsibilities may leave mothers with very little
    time or energy to devote to their infants when they are at home together (Hochschild, 1989; Rachlin, 1987).
    Similarly, it is likely that some stay-at-home mothers focus on spending a lot of high-quality interaction time with
    their children, whereas others are mostly present in the home while engaging in other primary activities (Baydar
    et al., 1999; Bianchi, 2000; Nock &Kingston, 1988).
    Some of the variance in the amount of time mothers and infants spend together may be due, in part, to
    demographic factors. Maternal education, for example, is positively related to amount (e.g., Bryant &Zick, 1996;
    Hill &Stafford, 1980) and quality (e.g., Clarke-Stewart, Gruber, &Fitzgerald, 1994; NICHD ECCRN, 1999) of
    motherchild social interaction.
    Another source of individual differences in the time mothers spend with their infants may be the mothers’
    psychological characteristics. For example, maternal separation anxiety may positively affect the extent to which
    employed mothers are motivated to spend time with their infants when they are not at work. In support of this
    hypothesis, Bradley, Whiteside-Mansell, Brisby, and Caldwell (1997) found that greater maternal separation
    anxiety was related to mothers’ having greater socioemotional investment in their children. Also, Fagan (1994)
    found that among employed mothers, greater maternal separation anxiety was positively related to time spent
    with their infants in on-site child-care settings.
    Attitudes about employment also may affect the extent to which mothers spend quality time with their infants.
    Mothers who believe that the consequences of maternal employment for children are relatively negative are less

    10 February 2015 Page 2 of 12 ProQuest

    likely to be employed and are less likely to view maternal employment as acceptable at younger child ages
    (Greenberger, Goldberg, Crawford, &Granger, 1988). If employed mothers must spend long hours away from
    their children despite negative attitudes about employment consequences, we would expect these mothers to
    maximize the amount of time they spend with their children when they have the opportunity to be together.
    Nock and Kingston (1988) have suggested that fathers may compensate for the decreased time spent by
    employed mothers with their children, thereby reducing the potential negative effects of maternal employment
    on child outcomes. However, both Sanik (1990) and Douthitt (1989) found that fathers’ hours of caring for their
    children did not differ as a function of maternal employment, even though these hours have increased in the
    past few decades. Although the present study focuses primarily on the mother-infant relationship, we also
    sought to determine whether fathers’ involvement with their infants varied according to the time these infants
    spent apart from their mothers, and the effects of both father involvement and mother-infant time on child
    outcomes.
    The following questions were addressed in the present study: Among families in which the study infants spent
    more than 30 hours per week in child care, versus those in which child care was not used, (a) How do the
    mothers compare in the amount of time spent in instrumental care and social interaction with their infants? (b)
    How do the mothers compare in the quality of interaction? (c) Is the quality of mother-infant interaction related to
    the amount of time they spend together? (d) Do mothers’ psychological characteristics and fathers’ involvement
    differ by group, and are they related to the amount of time mothers spend with their infants? and (e) Do the
    quantity and quality of maternal care and father involvement predict child outcomes at age 15 months?
    METHOD
    Participants
    Data were analyzed from the NICHD Study of Early Child Care, a prospective longitudinal study of the effects of
    child care on children’s development. Participants were recruited during the first 11 months of 1991 from
    hospitals at 10 research sites that were located in or near Little Rock, Arkansas; Irvine, California; Lawrence,
    Kansas; Boston, Massachusetts; Philadelphia, Pennsylvania; Pittsburgh, Pennsylvania; Charlottesville, Virginia;
    Morganton, North Carolina; Seattle, Washington; and Madison, Wisconsin. During selected sampling periods,
    all women giving birth in each hospital were screened. Mothers were excluded if they were giving the baby up
    for adoption, had a known or acknowledged history of substance abuse, were under 18 years of age, did not
    speak English, planned to move in the next year, or lived outside the area or in a neighborhood considered
    unsafe for visits; mothers were also excluded if the baby was part of a multiple birth, was not discharged within
    7 days of birth, or had a congenital disability (see NICHD ECCRN, 1999, for more details).
    Of the 1,364 participating mothers, 1,171 completed at least one time-use interview when their infants were 7
    months of age. However, the sample for the present paper was further reduced to 326 because it included only
    (a) mothers who were married or partnered and lived in the same household as the spouse or partner; (b)
    mothers who completed the time-use interview on two occasions-one weekday and one weekend day (and, if
    the mother was employed, one of these days had to be a work day and the other a nonwork day); (c) mothers of
    infants spending 0 hours in nonmaternal child care from birth to 6 months of age (At-Home group; n = 183) or
    mothers of infants spending an average of 30 or more hours per week in child care from birth to 6 months (In-
    Care group; n = 143). Fathers also participated in the study at 6 of the 10 sites. Among the 326 families, data
    were available for 126 fathers (64 in the At-Home group and 62 in the In-Care group).
    Demographic characteristics of the At-Home group, the In-Care group, and the remaining families whose data
    were not included (n = 845) are shown in Table 1. Compared with the nonincluded mothers, the mothers in the
    present report were significantly older (29.27 vs. 28.07 years), t(1,169) = 3.32, p = .001. The groups did not
    differ in parental education, family income-to– needs ratio, number of children, child gender, or ethnicity.
    None of the mothers in the At-Home group was employed or in school from birth through 6 months, and none of
    the children in this group spent any time in nonmaternal child care. Most of the In-Care group mothers (n = 135)

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    were employed or in school at least 30 hours per week (M = 40.42 10.34 hours), and their children were in child
    care for a mean of 36.01 ( 4.78) hours per week.
    Demographic Variables
    When the infants were 1 month old, mothers were interviewed at home to obtain information about the mother’s
    age and parents’ education; the infant’s gender, birth order, and ethnicity. The family income-to-needs ratio was
    obtained at 6 months. The income-to-needs ratio is an index of family economic resources, with higher scores
    indicating greater financial resources per person in the household. Family income (exclusive of welfare
    payments) was divided by the poverty threshold, which was based on total family size and number of children
    under 18 years of age.
    Psychological Characteristics of Mothers
    The mothers’ psychological characteristics were assessed during home visits when the infants were 1 and 6
    months of age.
    Maternal separation anxiety. The Maternal Separation Anxiety Scale is a 21-item questionnaire adapted from
    Hock, Gnezda, and McBride (1983). Each item is rated on a 5-point Likert scale ranging from 1 (strongly
    disagree) to 5 (strongly agree). The items assess the mother’s sadness, worry, and guilt about separation from
    her infant; beliefs about the importance of maternal care and her infant’s preference for maternal care; and
    beliefs about her infant’s ability to adapt to nonmaternal care. Cronbach’s alphas were .93 at both 1 and 6
    months. An average score was computed across ages.
    Attitudes about maternal employment. At the 1month home visit the mothers completed 11 items of the Beliefs
    About the Consequences of Maternal Employment for Children (Greenberger et al., 1988). The scale, which
    uses 6-point Likert ratings (1 = disagree very strongly to 6 = agree very strongly), yields Benefits and Costs
    scores. A high score on the Costs subscale (Cronbach’s alpha = .88) reflects the belief that children are likely to
    have problems if their mothers are employed (e.g., “Children are less likely to form a warm and secure
    relationship with a mother who is working full time”).
    Father Involvement in Caregiving
    When the infants were 6 months old, fathers at 6 of the 10 study sites completed a set of questionnaires,
    including one describing their caregiving activities with the study child (NICHD ECCRN, 2000). The 11
    caregiving activities (which included items such as bathing, feeding, reading to the infant, attending to the infant
    when crying) were rated on a 5-point scale (1 = partner’s job, 3 = we share equally, 5 = my job) and summed to
    yield a total score for Father Involvement in Caregiving (Cronbach’s alpha = .77).

    Quantity of Mother-Infant Interaction
    Quantity of mother-infant interaction was assessed when the infants were 7 months old, using a telephone time-
    use interview with the mother on two occasions-one describing the immediately prior weekday-workday
    (Monday through Thursday) and the other, the prior weekend-nonwork day (Saturday or Sunday).
    The interview is a chronological account of what the mother did during the entire 24-hour period beginning at 1
    minute after midnight on the previous day. The mother identified (a) her primary activity, (b) activity beginning
    and end times, (c) her location, (d) the infant’s location, and (e) any secondary activity. Activity codes included
    Caring for Child (instrumental care, interaction, supervision or discipline, helping or teaching, organized outings,

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    outdoor play, other child care), Paid Work, Household Activity, Travel, Personal Care, Education/Training,
    Organizational Activities, Social Activity, Quiet Leisure.
    The activity codes yielded two summary variables, computed separately for weekdays and weekends:
    Instrumental Care consisted of the total amount of time per day that the mother engaged in instrumental care,
    supervision or discipline, and other child care with the study child as either primary or secondary activities.
    Social Interaction consisted of the total amount of time per day that the mother spent interacting, helping, or
    teaching, and being on organized outings with the study child as primary or secondary activities.
    The validity of short-term recall methods of time-use data collection has been demonstrated via comparison with
    a variety of other methods (Juster &Stafford, 1985; see Robinson, 1999). Within the NICHD data set, validity
    data were obtained at one of the sites by use of the Experience Sampling Method (Larson &Csikszentmihalyi,
    1983) at 7 months of age for 48 families who were called 60 times over 4 weeks. The percentage of calls in
    which the mother was interacting with the child correlated at r = .56 with the total amount of mother-child
    interaction (instrumental care plus social interaction) assessed via the time-use calls.
    Quality of Interaction
    Sensitivity in the HOME. The Infant/Toddler Home Observation for Measurement of the Environment (HOME;
    Caldwell &Bradley, 1984) was administered during the 6-month home visit. The HOME is a semistructured
    interview/observational procedure in which a home visitor answers a set of binary questions based upon
    maternal response to specific queries and makes observations of materials in the home and the mother’s
    behavior toward the child. Factor analysis of the items on the HOME yielded two relevant factor scores, Positive
    Involvement and Lack of Negativity. The former scale comprised six items assessing the extent to which the
    mother was positively responsive and affectionate to her infant during the home visit. The latter scale comprised
    five items measuring the extent to which the mother refrained from behaving in a negative manner toward her
    infant (e.g., shouting, spanking, annoyance, restriction) during the visit. The two scale scores were summed to
    produce a composite score for Sensitivity in the HOME.
    Child Outcomes
    The specific child outcomes were selected to broadly represent important areas of development at 15 months-
    cognition, language, social engagement, and attachment security.
    Bayley Mental Development Index. The Bayley Mental Development Index (MDI) (Bayley, 1969) is the most
    widely used measure of cognitive developmental status for children in the first 2 years of life. The assessment
    measures sensory perceptual acuity and discrimination; memory, learning, and problem solving; early verbal
    communication; and the ability to form generalizations and classifications. The MDI was administered in a
    laboratory playroom setting at 15 months of age by trained examiners.
    MacArthur Communication Development Inventory. The Communication Development Inventory (CDI) (Fenson,
    Dale, Reznick, Thai, &Reilly, 1991) assesses early language development via a 493-item inventory that was
    completed by the mothers when their children were 15 months old. The infant version of the CDI includes a 396-
    item vocabulary checklist on which the mother indicates which words her child uses and which words her child
    understands. Separate percentile scores for vocabulary production and vocabulary comprehension were
    computed.

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    Child engagement. During a home visit, mothers were asked to have their infants play with ageappropriate toys
    in three containers in a set order for 15 minutes. Mother-infant interaction was videotaped, and the tapes from
    all sites were shipped to a central location for coding. A series of 4-point ratings was used to characterize the
    behaviors of the mothers and infants separately. Two of the ratings of child behavior–child engagement and
    positive mood-were summed to yield a child engagement composite. Cronbach’s alpha for the composite at 15
    months was .58, and reliability was .74.
    CONCLUSION
    In summary, our results indicate that among mothers whose infants were in 30 or more hours per week of child
    care, the “cost” in terms of reduced mother-infant interaction time was considerably less than expected, and the
    quality of mother-infant interaction did not appear to be affected by the amount of time spent apart. It is likely
    that these mothers attempted to compensate for time spent apart by focusing increased attention on their
    infants during the weekend, and this was especially true if the mother was concerned about her separation from
    the infant and the effects of her employment on the child. Fathers, as well, may have attempted to compensate
    for maternal employment hours by being more involved with their infants.
    Compared with prior maternal time-use studies, our investigation focused on a number of unique areas.
    Namely, we addressed psychological predictors of the quantity of time mothers spent interacting with their
    infants, the relation between quantity and quality of interaction, and the consequences for the infant’s
    development of the quantity and quality of maternal care. Additionally, we identified the importance of
    considering weekday and weekend time separately.
    It is clear that the data in this report have provided a first step toward expanding the study of maternal time use,
    but it is also clear that the results have raised additional questions that can be answered only in the context of
    longitudinal in-depth research that includes more extensive time-use data and that includes both parents.
    Perhaps the most important of these questions is the extent to which the quantity of parent-child interaction is
    related to child outcomes over time and at older ages. Although time-use researchers have tended to assume
    that parents who spend a lot of time with their infants are providing high-quality parenting that will promote
    optimal development, our results suggest the need for careful consideration of the complex relations between
    the quantity of interaction, the quality of parenting, and child outcomes.
    Footnote
    NOTE
    Footnote
    The authors are investigators in the NICHD Study of Early Child Care and acknowledge the generous support of
    their time by the National Institute of Child Health and Human Development (Grants HD25447, HD25456,
    HD27040, HD25451). The study is directed by a steering committee and supported by NICHD through a
    cooperative agreement (UlO) that calls for scientific collaboration between the grantees and the NICHD staff.
    The authors would like to thank the coinvestigators who worked with them on the design of the larger study, the
    site coordinators and research assistants who collected the data, and the families and teachers who continue to
    participate in this longitudinal study.
    References
    REFERENCES
    Ainsworth, M. D., Blehar, M. C., Waters, E., &Wall,
    S. (1978). Patterns of attachment: A psychological
    References
    study of the Strange Situation. Hillsdale, NJ: Lawrence Erlbaum.
    Baumrind, D. (1989). Rearing competent children. In W Damon (Ed.), Child development today and tomorrow
    (pp. 349-378). San Francisco: Jossey-Bass.
    Baydar, N., Greek, A., &Gritz, R. M. (1999). Young mothers’ time spent at work and time spent caring for

    10 February 2015 Page 9 of 12 ProQuest

    children. Journal of Family and Economic Issues, 20, 61-84.
    References
    Bayley, N. (1969). Bayley Scales of Infant Development. New York: Psychological Corporation.
    Bianchi, S. M. (2000, March). Maternal employment and time with children: Dramatic change or surprising
    continuity? Presidential address at the meeting of the Population Association of America, Los Angeles, CA.
    Bradley, R. H., Whiteside-Mansell, L., Brisby, J. A., &Caldwell, B. M. (1997). Parents’ socioemotional investment
    in children. Journal of Marriage and the Family, 59, 77-90.
    References
    Brazelton, T B. (1986). Issues for working parents. American Journal of Orthopsychiatry, 56, 14-25.
    Bryant, W. K. (1992). Human capital, time use, and other family behavior. Journal of Family and Economic
    Issues, 13, 395-405.
    Bryant, W. K., &Zick, C. D. (1996). An examination of parent-child shared time. Journal of Marriage and the
    Family, 58, 227-237.
    Caldwell, B. M., &Bradley, R. H. (1984). Home Observation for Measurement of the Environment. Little Rock:
    University of Arkansas at Little Rock.
    Clarke-Stewart, K. A., Gruber, C. P., &Fitzgerald, L. M. (1994). Children at home and in day care. Hillsdale, NJ:
    Lawrence Erlbaum.
    De Wolff, M. S., &van Ijzendoorn, M. H. (1997). Sensitivity and attachment: A meta-analysis on parental
    antecedents of infant attachment. Child Development, 68, 571-591.
    Douthitt, R. A. (1989). The division of labor within the home: Have gender roles changed’? Sex Roles, 20, 693-
    704.
    References
    Fagan, J. (1994). Correlates of maternal involvement in on-site and off-site day care centers. Child and Youth
    Care Forum, 23, 275-290.
    Fenson, L., Dale, P S., Reznick, J. S., Thai, D., &Reilly, J. S. (1991). Technical manual for MacArthur
    Communicative Development Inventories. San Diego, CA: San Diego State University.
    Greenberger, E., Goldberg, W., Crawford, T J., &Granger, J. (1988). Beliefs about the consequences of
    maternal employment for children. Psychology of Women Quarterly, 12, 35-59.
    Hill, R. C., &Stafford, E P (1980). Parental care of children: Time diary estimates of quantity, predictability, and
    variety. Journal of Human Resources, 15, 219-239.
    References
    Hilton, J. M. (1990). Differences in allocation of family time spent on household tasks among single-parent, one-
    earner, and two-earner families. Lifestyles: Family and Economic Issues, 11, 283-298.
    Hochschild, A. (1989). The second shift: Working parents and the revolution at home. New York: Viking. Hock,
    E., Gnezda, M. T, &McBride, S. L. (1983).
    Mothers of infants: Attitudes toward employment and
    References
    motherhood following birth of the first child. Journal of Marriage and the Family, 46, 425-431.
    Hofferth, S. L., Brayfield, A., Deich, S., &Holcomb, P (1991). National child care survey, 1990. Washington, DC:
    Urban Institute Press.
    Juster, F T, &Stafford, F P (Eds.) (1985). Time, goods, and well-being. Ann Arbor, MI: Survey Research Center,
    Institute for Social Research.
    Kelly, J. E, &Barnard, K. E. (2000). Assessment of parent-child interaction: Implications for early intervention. In
    J. P Shonkoff &S. J. Meisels (Eds.), Handbook of early childhood intervention (pp. 258289). Cambridge, UK:
    Cambridge University Press.
    Lamb, M. E. (1998). Nonparental child care: Context, quality, correlates. In W. Damon, I. E. Sigel, &K. A.

    10 February 2015 Page 10 of 12 ProQuest

    Renninger (Eds.), Handbook of child psychology (Vol. 4, 5th ed., pp. 73-134). New York: Wiley.
    Larson, R., &Csikszentmihalyi, M. (1983). The experience sampling method. New Directions for Methodology of
    Social and Behavioral Science, 15, 4156.
    References
    NICHD Early Child Care Research Network. (1997). The effects of infant child care on infant-mother attachment
    security: Results of the NICHD Study of Early Child Care. Child Development, 68, 860-879.
    NICHD Early Child Care Research Network. (1999). Child care and mother-child interaction in the first three
    years of life. Developmental Psychology, 35, 1399-1413.
    NICHD Early Child Care Research Network. (2000). Factors associated with fathers’ caregiving activities and
    sensitivity with young children. Journal of Family Psychology, 14, 200-219.
    NICHD Early Child Care Research Network. (in press). Parenting and family influences when children are in
    child care: Results from the NICHD Study of Early Child Care. In J. G. Borkowski, S. Ramey, &M. Bristol-Power
    (Eds.), Parenting and the child’s world: Influences on intellectual, academic, and social-emotional development.
    Mahwah, NJ: Lawrence Erlbaum.
    Nock, S., &Kingston, P W. (1988). The division of leisure and work. Social Science Quarterly, 70, 2439.
    References
    Rachlin, V. C. (1987). Fair vs. equal role relations in dual-career and dual-earner families: Implications for family
    interventions. Journal of Applied Family and Child Studies, 36, 187-192.
    Robinson, J. P (1999). The time-diary method: Structure and uses. In W. E. Pentland, A. S. Harvey, M. P
    Lawton, &M. McColl (Eds.), Time use research in the social sciences (pp. 47-89). New York: Kluwer
    Academic/Plenum Publishers.
    Sanik, M. M. (1990). Parents’ time use: A 1967-1986 comparison. Lifestyles, 11, 299-316.
    Thompson, R. A. (1998). Early sociopersonality development. In W. Damon &N. Eisenberg (Eds.), Handbook of
    child psychology (Vol. 3, 5th ed., pp. 25104). New York: Wiley.
    Walker, K. E., &Woods, M. E. (1976). Time use: A measure of household production of family goods and
    services. Washington, DC: Center for the Family of the American Home Economics Association.
    Weinraub, M., Jaeger, E., &Hoffman, L. (1988). Predicting infant outcome in families of employed and
    nonemployed mothers. Early Childhood Research Quarterly, 3, 361-378.
    AuthorAffiliation
    CATHERINE L. BOOTH University of Washington
    K. ALSION CLARKE-STEWART University of California-Irvine*
    DEBORAH LOWE VANDELL University of Wisconsin**
    KATHLEEN MCCARTNEY Harvard University***
    MARGARET TRESCH OWEN University of Texas-Dallas****
    AuthorAffiliation
    Department of Family &Child Nursing, University of Washington, CHDD 106 South Building, Box 357920,
    Seattle, WA 98195-7920 (ibcb@u.washington.edu).
    AuthorAffiliation
    *Department of Psychology and Social Behavior, University of California-Irvine, 3340 Social Ecology 11, Irvine,
    CA 92697-7085.
    **Department of Educational Psychology, University of Wisconsin, 1025 West Johnson Street, Room 467,
    Madison, WI 53706.
    AuthorAffiliation
    ***Harvard Graduate School of Education, Harvard University, 704 Larsen Hall, Appian Way, Cambridge, MA
    02138.
    ****School of Human Development, University of Texas– Dallas, P 0. Box 830688, Mail Station GR 41,

    10 February 2015 Page 11 of 12 ProQuest

    Richardson, TX 75083-0688.
    Subject: Comparative studies; Mothers; Babies; Child care;
    Publication title: Journal of Marriage and Family
    Volume: 64
    Issue: 1
    Pages: 16-26
    Number of pages: 11
    Publication year: 2002
    Publication date: Feb 2002
    Year: 2002
    Publisher: Blackwell Publishing Ltd.
    Place of publication: Minneapolis
    Country of publication: United Kingdom
    Publication subject: Public Health And Safety, Matrimony, Education, Sociology, Children And Youth – About
    Source type: Scholarly Journals
    Language of publication: English
    Document type: Feature
    ProQuest document ID: 219764964
    Document URL: http://nclive.org/cgi-
    bin/nclsm?url=http://search.proquest.com/docview/219764964?accountid=11330
    Copyright: Copyright National Council on Family Relations Feb 2002
    Last updated: 2014-06-21
    Database: ProQuest Central

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