Infant feeding and child fussy eating: The Generation R Study.

Fussy/picky eating - i.e. consistently avoiding certain foods - is common in childhood and can be worrisome for parents. Repeated exposure to various flavors as occurs in breastmilk and early exposure to complementary feeding may increase food acceptance and thereby decrease fussy eating. This study examines the associations between infant feeding and child fussy eating in 4779 participants of Generation R, a Dutch population-based cohort. Breastfeeding initiation and continuation, and timing of complementary feeding were assessed by questionnaires at 2, 6, and 12 months. The food fussiness scale of the Children's Eating Behaviour Questionnaire was administered at 4 years. Linear regression analyses were performed, adjusted for confounders. Children who were never breastfed did not differ in fussy eating frequency from children breastfed for 6 months or longer. However, children who were breastfed for less than 2 months had a 0.70 points higher food fussiness sum-score (95%CI:0.27; 1.12) than children breastfed for 6 months or longer. An earlier introduction of vegetables was associated with less fussy eating behavior (p-for-trend:0.005). Particularly children who were introduced to vegetables between 4 and 5 months had a 0.60 point lower food fussiness score (95%CI: 1.06;-0.15) than children introduced to vegetables after 6 months. An early introduction to fruits or any solids was not significantly related to fussy eating, although the effect estimates were in the same direction as for introducing vegetables early. Results suggest that breastfeeding does not predict fussy eating. However, introducing vegetables into a child's diet before 5 months might be protective against fussy eating, although future research should account for parents' own fussy eating.

Bi-directional associations between child fussy eating and parents' pressure to eat: Who influences whom?

BACKGROUND: Fussy eating is common in young children, often raising concerns among parents. The use of pressuring feeding practices may provoke or worsen child fussiness, but these practices could equally be a parent's response to child fussy eating. OBJECTIVE: In longitudinal analyses, we assessed directionality in the relation between fussy eating and parent's pressure to eat across childhood. METHODS: Study participants were 4845 mother-child dyads from the population-based Generation R cohort in the Netherlands. The Child Behavior Checklist was used to assess fussy eating (2 items) at child ages 1½, 3 and 6years. Parents' pressure to eat was assessed with the Child Feeding Questionnaire (4 items) when children were 4years old. All scale scores were standardized. RESULTS: Linear regression analyses indicated that preschoolers' fussy eating prospectively predicted higher levels of parents' pressure to eat at child age 4years, independently of confounders (adjusted B=0.24, 95% CI: 0.21, 0.27). Pressure to eat at 4years also predicted more fussiness in children at age 6years, independently of confounders and of fussy eating at baseline (adjusted B=0.14, 95% CI: 0.11, 0.17). Path analyses indicated that the relation from fussy eating at 3years to parenting one year later was stronger than from pressure at 4years to fussy eating two years later (p<0.001). CONCLUSIONS: Our findings suggest bi-directional associations with parental pressuring feeding strategies being developed in response to children's food avoidant behaviors, but also seemingly having a counterproductive effect on fussiness. Thus, the use of pressure to eat should be reconsidered, while providing parents alternative techniques to deal with their child's fussy eating.

Maternal history of eating disorders: Diet quality during pregnancy and infant feeding.

We studied associations of maternal history of eating disorders (EDs) with diet quality of pregnant women and their infants, and breastfeeding practices. We included 6196 mother-child pairs from Generation R, a population-based cohort in the Netherlands. Maternal history of lifetime EDs was assessed during pregnancy with a questionnaire. Dietary intake during pregnancy and in infancy was assessed with food-frequency questionnaires and diet quality scores were calculated, reflecting adherence to dietary guidelines. Breastfeeding practices were assessed with questionnaires at 2, 6, and 12 months. We observed that, after adjustment for socioeconomic and lifestyle factors, women with a history of EDs had a higher diet quality than women without a history of EDs (B = 0.24 SD, 95%CI: 0.15; 0.33). Mothers with a history of EDs were less likely to breastfeed (unadjusted OR = 0.68, 95%CI: 0.51; 0.93), although no longer statistically significant after adjustment (OR = 0.75, 95%CI: 0.55; 1.03). These findings suggest that mothers with a history of EDs seem slightly less likely to initiate breastfeeding, however, this warrants further investigation. At the age of 1 year, infants of mothers with a history of EDs had a higher diet quality (B = 0.15 SD, 95%CI: 0.02; 0.27). We conclude that mothers with a history of EDs and their infants have a relative good diet quality, although follow-up studies are needed to assess long-term associations with diet in later childhood and adolescence.

Are parents' anxiety and depression related to child fussy eating?

OBJECTIVE: To examine the association between parental anxiety and depression with child fussy eating-that is, consistent rejection of particular food items. DESIGN: This study was embedded in Generation R, a prospective cohort from fetal life onwards in the Netherlands. SETTING: Population-based. PARTICIPANTS: 4746 4-year-old children and their parents. EXPOSURE: Parental internalising problems (ie, symptoms of anxiety and depression) were assessed with the Brief Symptoms Inventory during pregnancy and the preschool period (child age 3 years). MAIN OUTCOME MEASURE: The food fussiness scale of the Children's Eating Behaviour Questionnaire. RESULTS: Maternal anxiety during pregnancy and during the child's preschool period was related to higher food fussiness sum-scores in children. For instance, per point on the anxiety scale in pregnancy, children had on average a 1.02 higher sum-score (95% CI 0.59 to 1.46) on the food fussiness scale, after adjustment for confounders. Likewise, mothers' depressive symptoms at both time points were associated with fussy eating behaviour in their children (eg, in the antenatal period: per point on the depression scale, children had a 0.91 point higher sum-score on the food fussiness scale, 95% CI 0.49 to 1.33). We found largely similar associations between fathers' internalising problems and children's fussy eating. However, fathers' anxiety during the antenatal period was not related to child fussy eating. CONCLUSIONS: Maternal and paternal internalising problems were prospectively associated with fussy eating in preschoolers. Healthcare practitioners should be aware that non-clinical symptoms of anxiety and depression in parents are risk factors for child fussy eating.

Behavioral outcomes of picky eating in childhood: a prospective study in the general population.

BACKGROUND: Picky eaters in the general population form a heterogeneous group. It is important to differentiate between children with transient picky eating (PE) and persistent PE behavior when adverse outcomes are studied. We analyzed four PE trajectories to determine the associations with child mental health prospectively. METHODS: From a population-based cohort, 3,748 participants were assessed for PE at 1.5, 3, and 6 years of age using maternal reports. Four trajectories were defined: persistent (PE at all ages); remitting (PE before 6 years only); late-onset (PE at 6 years only); and never (no PE at any assessment). Child's problem behaviors were assessed with the Teacher's Report Form at 7 years of age. We examined associations between picky eating trajectories and emotional problems, behavioral problems and pervasive developmental problems using logistic regressions. Analyses were adjusted for child, parental, and socioeconomic confounders. We also adjusted for maternal-reported baseline problem behavior at age 1.5 years; the never picky eating group was used as reference. RESULTS: Persisting PE predicted pervasive developmental problems at age 7 years (OR = 2.00, 95% CI: 1.10-3.63). The association remained when adjusted for baseline pervasive developmental problems at 1.5 years (OR = 1.96, 95% CI: 1.10-3.51). Persistent PE was not associated with behavioral (OR = 0.92, 95% CI: 0.53-1.60) or emotional problems (OR = 1.24, 95% CI: 0.74-2.07). Other PE trajectories were not related to child behavioral or emotional problems. CONCLUSIONS: Persistent PE may be a symptom or sign of pervasive developmental problems, but is not predictive of other behavioral problems. Remitting PE was not associated with adverse mental health outcomes, which further indicates that it may be part of normal development.

Longitudinal association between preschool fussy eating and body composition at 6 years of age: The Generation R Study.

BACKGROUND: Children's fussy eating behavior has been related to both underweight and overweight in cross-sectional studies, but the direction of these associations and the relation with more detailed measures of body composition remains unclear. We aimed to examine whether fussy eating at age 4 years is longitudinally related to body mass index (BMI), fat mass index (FMI) and fat-free mass index (FFMI) at 6 years of age. METHODS: This study was embedded in Generation R, a population-based, prospective cohort. Data were available for 4191 children. The Children's Eating Behaviour Questionnaire (CEBQ), administered at age 4 years, was used to derive a fussy eating profile. This profile is characterized by high scores on food avoidant scales and low scores on food approach scales. At age 6 years, height and weight were measured at our research center. Body fat and fat-free mass were measured using Dual-energy-X-ray absorptiometry. We used age- and sex-specific standard deviation scores (SDS) for all outcomes. RESULTS: After adjustment for confounders, the fussy eating profile was related to lower BMI-SDS (B = -0.37, 95% CI: -0.47;-0.26), lower FMI-SDS (B = -0.22, 95 % CI: -0.33;-0.12) and lower FFMI-SDS (B = -0.41, 95% CI: -0.54;-0.29). When adjusting for baseline BMI at 4 years, the fussy eating profile predicted a 0.11 lower BMI-SDS at age 6 (95% CI: -0.19;-0.04). This change in BMI was mainly due to a decrease in FFMI (B = -0.19, 95% CI: -0.29;-0.09). Fussy eaters also had a higher risk of becoming underweight than non-fussy eaters (OR = 2.28, 95% CI: 1.34;3.87). CONCLUSIONS: Our findings suggest that young fussy eaters are at risk of having a lower fat free mass and of becoming underweight over a 2-year period. This implies that fussy eaters may benefit from careful monitoring to prevent an adverse growth development.

Does maternal history of eating disorders predict mothers' feeding practices and preschoolers' emotional eating?

We aimed to examine whether a maternal history of eating disorders predicted mothers' feeding practices and preschoolers' emotional eating patterns. Data were available from 4851 mothers and their children, who participated in a Dutch population-based cohort study (the Generation R Study). Maternal history of lifetime eating disorders was assessed during pregnancy using a self-report questionnaire. Mothers filled out the Child Feeding Questionnaire and the Child Eating Behaviour Questionnaire when children were four years old. Linear regression analyses were performed, adjusting for potential confounders. Of all mothers, 8.6% had a history of an eating disorder (2.5% anorexia nervosa (AN); 3.9% bulimia nervosa (BN); 2.2% both AN and BN). Compared to mothers without a history of eating disorders, mothers with a history of eating disorders, in particular AN, used less pressuring feeding strategies (standardized B = -0.30; 95% CI: -0.49, -0.11). Children of mothers with a history of AN had relatively high levels of emotional overeating (standardized B = 0.19; 95% CI: 0.00, 0.39). Maternal history of BN was not related to mothers' feeding practices or children's emotional eating. Overall, the levels of emotional overeating among children of mothers with a history of eating disorders are noteworthy, particularly considering the young age (4 years) of participating children. This finding may reflect an effect of maternal eating disorders on the development of disordered eating patterns, but could also be subject to mothers' perception.