Supporting Healthy Eating at Home: A Training Module for Home Visitors

Module One: Parent Provides. Child Decides

Narrator: Supporting Healthy Eating at Home: A Training Module for Home Visitors.

Welcome to Module One: Parent Provides. Child Decides.

This PowerPoint introduces the concept of responsive feeding. Responsive feeding is a key dimension of responsive parenting involving reciprocity between child and caregiver during the feeding process. Caregivers are responsible for offering healthy meals and snacks to children. Children are responsible for deciding which and how much of the healthy foods offered they would like to eat. We often refer to this as parent provides, child decides Babies are born with the capacity to self-regulate their energy intake. They understand when they're hungry and when they're full. It is the responsibility of the caregiver to nurture this skill by understanding when an infant, and later toddler and preschooler, is communicating signs of hunger or fullness. During the first year of life, infants and caregivers learn to recognize and interpret both verbal and non-verbal communication skills for one another, including signals of hunger and satiety. This reciprocal process forms the basis for the emotional bonding or attachment and is essential to healthy social-emotional functioning. This reciprocal process must continue in the toddler and preschool years to further support social-emotional functioning. Responsive feeding supports this attachment when the caregiver responds in a predictable manner to a child's signs of hunger or fullness.

The child learns their cues will be understood and respected consistently. Responsive feeding supports self-regulation skills early in life that may predict future food intake and our responses as adults to hunger and satiety. In other words, whether as adults we stop eating when we feel full or only eat when we feel hungry. However, this can feel antithetical to many parents and caregivers. We make many decisions for our children in a year, day, and even hour. Relinquishing that control and allowing the child to communicate their own desires and make their own decisions is truly a skill -- a skill that takes patience, practice, and support -- support that you, as a home visitor, are primed to provide. Responsive feeding is grounded on three steps. The child provides a sign they are hungry or full. The caregiver recognizes and responds to these cues in an emotionally supportive and developmentally appropriate manner. This manner becomes predictable to the child. They know their cues will be understood and respected consistently. Caregivers need specific skills and knowledge in order to responsibly feed their child. They must understand and be able to articulate their child's individual signs of hunger and satiety. They must know how to determine when their child is ready for solids, including what developmental milestones signal a readiness for solid foods, and they need to be aware of appropriate foods and amounts to serve an infant, toddler, and preschooler.

This is where you can support families. Help parents build the necessary knowledge and skills in order to responsibly feed their child. Remember. A responsive feeding approach has many immediate benefits such as social-emotional functioning, but also sets the child on a path for long-term healthy diet and weight. Before you review infant feeding practices and hunger and satiety cues, it may be helpful to stop and reflect on your own perceptions of infant feeding, healthy infant weight, and the perceptions the families you work with may have. The next several slides provide an overview of the feeding needs during infancy. The first year of life is a period marked by the most rapid growth and physical development experienced throughout life. Infants should be fed on-demand, typically 10 to 12 times a day during the initial weeks of life, and eight to 12 times per day over the next few months. Infants younger than six months should only be given formula or breast milk and held while being fed. This is an opportunity for caregivers to bond with the baby. Hopefully, they can find a quiet space to hold the infant, make eye contact, talk to them, and look or listen for cues of fullness. Infants should never be given a propped bottle or given bottles while in the crib or allowed to walk around with a bottle. This doesn't allow responsive feeding practices such as building social-emotional functioning, since it lacks the one on one interaction between caregiver and child, nor does it support a caregiver listening and responding to hunger and satiety cues. Every infant is different.

They each have their own ways of telling you when they're hungry and when they are full. It is important to engage the family in a discussion of each individual child's cues. If the parents are unaware of them, this is a great opportunity to become aware of them together. It might be helpful to remind parents that understanding and responding to the early signs of hunger can prevent some of the less pleasant later signs of hunger, creating a more relaxed and enjoyable feeding for everyone. This is also an opportunity to remind families to look for their child's signs of fullness. This is often easier for breastfeeding families whose baby might fall asleep on the breast, stop latching, or turn their head away. Families who are bottle feeding may worry about wasting formula, and try to squeeze an extra ounce or two, even though their child is telling them they are full. Common signs of hunger for infants zero to three months includes putting his or her hands to their mouth, sucking, rooting, looking around for a nipple, pre-facial crying or grimacing, fussing, wakes, and tosses. Common cues of satiety include turning their head away from the nipple or bottle, falling asleep, showing interest in other things, closing the mouth, sealing their lips together, or spitting out the nipple.

As infants get a little older, around three to six months, their cues for hunger and satiety become more advanced. They are learning new ways of communicating. They might show they are hungry by moving their head towards the spoon or bottle, swiping food towards their mouth, crying or fussing, and during feedings, they may coo or smile at you to indicate they are still interested in eating. When they are full, they might lean away from the food, slow down or decrease the rate of sucking, spit out the nipple, turn away from the bottle, or start to become more interested in the spoon or other things. As mentioned earlier, responsive feeding includes a caregiver's ability to recognize and respond in an emotionally supportive and developmentally appropriate way. Therefore, caregivers need to understand important developmental milestones that signal a child's readiness for solid food.

Many parents are excited to introduce their child to solid food, however, introducing solid foods before a child is developmentally ready offers no nutritional advantages. Instead, it can lead to overfeeding, an improper balance of nutrients, substituting less nutritionally packed foods for breast milk or formula, and allergic reactions. We encourage families to wait until their baby is ready before starting solids, usually around six months. Families can look for signs such as fading of the tongue thrusting reflex. In other words, they are not pushing food out of their mouth and can move it to the back of their mouth. Babies zero to six months have a normal reflex of protruding the tongue out of the mouth when the lips are touched. This is a good thing for breast and bottle fed babies. It helps them latch. But this reflex usually goes away between four to six months, so babies can accept, manipulate, and swallow solid foods. If most of the food comes back out at you or baby sticks out his tongue before you get the spoon past his lips, he is not ready for solids. You can also look for signs that the sucking reflex has changed to allow coordinated swallowing.

When this happens, babies can move the food to the back of their mouth and swallow the food without choking in a coordinated manner. This goes along with the tongue thrust, but it can also be an indication that baby's mouth isn't mature enough to maneuver food from the front to the back to swallow. Sometimes, you'll see pocketing, where the food sits in baby's cheeks indefinitely. These babies may not have the sensory awareness to detect the food or know what to do with it. Try thickening the food to see if it helps. If it doesn't, baby is just not ready. Other signs to look for are when baby can sit with support, has good head and neck control. As infants reach developmental milestones, they will be able to tell caregivers in different ways when they are hungry and when they are full. Infants age six to nine months are considered middle infancy, and can usually tell caregivers they are hungry by reaching for their spoon or food or pointing to food. Sometimes they can even articulate sounds -- not necessarily words, but sounds a regular caregiver will learn to associate with hunger.

Signs of satiety at this age can typically be characterized by slowing during feeding time, clenching their mouth closed, or even pushing food away. You may even see the child playing with their food without showing interest in eating it. While you should allow infants to explore new foods and textures, when they show signs they are no longer hungry, then it is time to transition to a new interaction. As infants get closer to the toddler stage, they may express hunger in more sophisticated ways. They may reach for their spoon or food, point to food, get excited when food is present, or -- food with specific words or sounds. Some child care providers will even teach infants at this stage sign language to signal when they are hungry or want more food. This can help with frustration for both the hungry infant and busy parent.

Late infancy satiety cues might include slowing down while eating, clenching mouth shut or pushing food away, or even shaking their head, no, when asked if they want more. Infants at this age should be given tools to communicate their hunger or fullness to caregivers. It is also a prime opportunity to engage families in collaborating in efforts to build language skills during meal time. Around 9 to 12 months, infants will also begin drinking less breast milk or formula, but they still need at least 28 ounces of formula per day. They will begin to develop the pincher grasp, and you should always offer water instead of juice. Juice is not recommended for infants. The goal is to wean the baby from the bottle by 12 months, but no later than 18 months. Home visitors want to help families identify their own baby's hunger and satiety cues. Here are some questions you can ask with them.

How did your baby tell you when they are full or hungry? Sit quietly and look your baby in the eye. Your baby is learning who you are and how much you love them. And you can discuss with families how to know when their baby is ready to start solids. As babies grow into toddlers and preschoolers, their eating environment changes. They start to find independence, develop food jags where they eat the same food over and over, and build fine motor skills that allow them to use utensils and serve themselves. The responsive feeding habits built in the first year of life serve as the cornerstone of a positive eating environment. Did you know that the environment in which a child is fed, not just the foods they're fed, affect what and how much a child may eat? Research has linked non-ideal environments -- negative impact on intake and child weight. For example, conflict during meal time predicts a heavier weight in preschool children, or watching TV during mealtime predicted less healthy eating, such as food containing high fat, as well as low fruit and vegetable consumption. Families should approach meals as an opportunity to connect and bond with their child, as well as guide them to healthy eating habits. Remind them to establish an open rapport with their child and give them eye contact.

Turn off the TV and put away the phone. You can remind families their child is more likely to accept food offered to them when they receive positive comments from their parent or caregiver. In a cross-sectional observation study in Vietnamese mother/child pairs, it was found that children aged 12 to 18 months were nearly 2 and 1/2 times more likely to accept the food offered to them when they received positive comments from the parent or caregiver, compared to those who received no encouragement at all. Help families establish clear expectations and routines. They may not be able to eat meals as a family every single night, but set aside specific days or times when they can. Encourage families to keep this as a family event. The role of routines has been well established and is vital to supporting their child's success in kindergarten. In addition, routines such as family meal time have been associated with reduced odds of obesity in preschoolers. Routines around mealtimes, such as eating in the same place and at the same time ensure the child has a supportive and comfortable experience. To clear expectations within a positive eating environment, include the child's ability or responsibility to choose what foods from those offered they will eat and how much they will eat.

They are also able to decline food, decide when they're full, or change their minds and try something they already declined. Remember. Parent provides, child decides. Responsive feeding asks children to listen to their internal hunger and fullness cues, builds skills and self-control regarding food intake, promotes attentiveness and interest in feeding, and the ability to communicate their needs. The child must be given the opportunity to listen to these cues and the independence to make healthy choices. With all of that said, it does not mean the child controls the meal environment, only that the child has an opportunity to listen to their body. It is the parent's responsibility to offer healthy foods. The child should not be asked to choose between french fries and apple slices, but rather between apple and orange. The parent is also responsible for building meal time routines, including establishing a positive social environment.

The social environment in which children eat can affect their eating behaviors. If mealtime is used as a time of conflict or discipline, children have been shown to associate eating with those same feelings. Parent reports of negative mealtime practices, such as hurrying children to eat and requiring children to clean their plates were associated with higher child weight for health percentiles. Conversely, parents' healthful nutrition attitudes coincided with more pleasant mealtime experiences, fewer suboptimal mealtime practices, and fewer child eating problems.

Parents are also responsible for supporting their child's ability to listen to their body's cues of hunger and fullness. Controlling what and how much a child eats may affect a child's food preference, ability to regulate energy intake or listen to their own hunger and satiety cues, and the amount of food consumed. In other words, the positive eating environment creates happier, healthier, and less picky eaters. Take this time to stop and reflect about mealtimes in your own childhood. Did you have family meal routines? What were they like? Do you have happy memories? What did you learn about your family over food? M

any of us grew up with the clean your plate mentality, that we need to finish all the food on our plate, or we are wasteful. However, as we have discussed, children learn how much food to choose by listening to their own hunger cues. It can be very difficult to break this way of thinking about meal time. As home visitors, you can acknowledge your own history with this clean your plate mentality. Did you grow up this way? How do you think it affected your relationship with food? You can also help families. Ask them the same questions, and then to identify the type of relationship they want their children to have with food, remind families this is a learning process. Try encouraging one serving at a time with appropriate measuring spoons to encourage children serving themselves appropriate amounts and listening to their hunger cues. It can also help families get used to an unclean plate.

Children can learn to associate foods with aspects of positive or negative social context. Repeatedly presenting a food in a positive context results in increased liking for that food. In contrast, presenting foods in a social context that generates more negative emotions -- for example, coercing a child to consume a food by offering a reward leads to decreased liking or willingness to try new foods. You might need to help families think of other ways they may reward or redirect their child -- ways that do not involve food, such as a favorite toy, activity with mom, or book. Please also discourage replacing food as a reward or punishment with screen time. It is easier said than done to support a child's internal cues of fullness. As adults, we don't know when a child is truly full, and many of our go-to encouragements are often not truly asking a child to reflect on their body's cues for fullness. We often use statements like, eat more of that or make sure you get enough.

These statements don't seem as improper or inadequate, but they don't ask a child to stop and reflect on what their body is telling them. Instead, try statements only the child can answer such as, what does your tummy feel like or what does your tummy feel like when it is full? This is a nuanced and challenging skill that can have lasting impact on the healthy eating habits of children. However, it won't be easy for many families to make this switch from a parent-led food environment to a positive child-led food environment. You can help families build skills that encourage their child to understand and listen to their cues of hunger or fullness. Have they ever asked their child what their tummy feels like when it is full? You can problem solve common family concerns such as picky eaters or worrying that a child isn't eating enough. Meal routines and role modeling are powerful allies against a picky eater -- something we talk more about in our next module. Strategize how they might create a mealtime routine that works within their family schedule, goals, and challenges.

How often do they eat meals as a family? What are some things from their own childhood they wished they did more with their family? Families may need to start small, such as eating meals as a family once a week or turning off the TV during meals occasionally, but not every time. However, these small victories can easily be built into bigger ones as the family learns what works for them. And help them find ways to involve their children in mealtime. This can include setting the table, basic food prep such as washing fruits or vegetables, or even helping stir or mix ingredients. Also, give families ways they can encourage their children in positive interaction during meal time. Is there something from your lesson plan this week they can practice during family meal, such as colors, shapes, or counting?

Caregivers often attribute feeding problems to their child. They are just picky. But it may be easier to change children's behavior -- their willingness to try new foods -- by altering the caregiver's behavior. Time, perception, family, and culture may influence the feeding style of the parent or caregiver. For example, parents who dislike controlling behavior usually have demands on their time and resources, and feel pressured. The feeding environment may often be characterized by frustration and inattention to the child's verbal and internal cues. The child may often throw around or refuse to eat in order to attract the attention of their parents. Encourage families to use meal time as an opportunity to leave these stressors, even for a short while. Help them identify ways they can build a positive meal experience at home. While they are building these new healthy habits, remind parents to be patient. Encourage children to try new foods, but don't force them. Parent provides, child decides. Limit distractions, including screen time, to allow time to focus and talk with their child. Help families link new foods back to your lesson plans-- a child's favorite book, story, or even game. Get creative, especially with your picky eaters. Experiment with different food combinations, tastes, textures, and ways to encourage.

And help parents pick times for family meals when they won't be rushed. 30 minutes for a snack and 45 minutes for a meal should be plenty of time to choose healthy foods, introduce new ones, and encourage their child to lead the meal and have fun. If you are looking for additional support around healthy, active living, the behaviors we want families to adopt, and more strategies that may help your families, you may find the Growing Healthy suite of tools helpful.

You can find these on ECLKC within the National Center on Early Childhood Health and Wellness Healthy Active Living resources.