infant development, feeding skills, and relationships
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Infant Development, feeding skills, and relationships
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• What factors influence food choices, eating behaviors, and acceptance?
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Sociology of Food
• Food Choices– Availability– Cost– Taste– Value– Marketing Forces– Health– Significance
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Sociology of Food
• Hunger• Social Status• Social Norms• Religion/Tradition• Nutrition/Health
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Taste and Smell
• Initial experiences of flavors occur prior to birth
• Amniotic fluid flavors--- maternal diet• Breast milk odor/flavor-- maternal diet• Sweet preference (Lactose)
– More frequent and stronger sucking behavior in response to sucrose
– Ability to detect other flavors (ie salt) emerges later (~ 4 months)
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Mechanisms of Appetite Regulation
• Poorly and incompletely understood• Genetics• Pleasure-seeking and hedonic responses to feed intake
are mediated by humoral substances (endorphins, dopamine, etc)
• Interaction between hormones, nutrients, and neuronal signals with the CNS
• Appetite stimulus: ghrelin• Appetite inhibition: CCK, leptin, GLP-1 etc)• GI volume sensitive feedback loops (ie distention)
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The feeding relationship
• Nourishing and nurturing
• Supports developmental tasks
• Learning
• Relationship • Development• Emotion and
temperament
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Relationship
• Feeding is a reciprocal process that depends on the abilities and characteristics of both caregiver and infant/child
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Relationship
• The feeding relationship is both dependent on and supportive of infants development and temperament.
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Relationship
• Children do best with feeding when they have both control and support
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Healthy Feeding Cycle
• Child associates hunger with need to eat
• Child communicates need• Parent reads cues and provides• Child communicates satiety• Parent responds• Positive experience gained
• Parent anticipates physical needs
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Tasks
• Infant– time– how much– speed– preferences
• Parent– food choices– support– nurturing– structure and limits– safety
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Infant and Caregiver Interaction
• Readability
• Predictability
• Responsiveness
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Development
• Oral- Motor development
• Neurophysiologic development• Homeostasis• Attachment• Separation and individuation
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• Oral-motor development parallels psychosocial, neurophysiologic milestones of homeostasis, attachment, and separation/individuation
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Development of Infant Feeding Skills
• Birth– tongue is disproportionately large in comparison with
the lower jaw: fills the oral cavity – lower jaw is moved back relative to the upper jaw,
which protrudes over the lower by approximately 2 mm.
– tongue tip lies between the upper and lower jaws. – "fat pad" in each of the cheeks: serves as prop for
the muscles in the cheek, maintaining rigidity of the cheeks during suckling.
– feeding pattern described as “suckling”
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Development of Feeding Behavior
Age Reflexes Behavior
B-3 months Root, suck-swallow-breath
Suckling pattern of feeding
4-6 months Fading root/bite reflex Mature suck, brings objects to mouth, munching pattern
7-9 months Normal gag development
Munching, rotary chewing, sits alone, holds bottle alone
10-12 months Bites, brings food to mouth, drinks from cup, spoon feeds
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Age (months)
Development Feeding/oral sensorimotor
Birth to 4-6 Visual fixation and tracking, learning to control body against gravity, sitting with support near 6 months, rolling over, hand to mouth
Nipple feeding, hand on bottle (2-4 months), maintains semiflexed posture during feeding, promotion of infant-parent interaction
6-9 Sitting independently for short time, mouthing hand and toys, extended reach with pincer grasp, object permanence, stranger anxiety, crawling skills emerging
Feeding more upright position, spoon feeding smooth purees, suckle pattern-- suck, both hands hold bottle, finger feeding introduced, vertical munching, preference for parental feeding
9-12 Pulling to stand, cruising, first steps by 12 months, some independent spoon feeding, refining pincer grasp
Cup drinking, eats lumpy/mashed foods, finger feeding, chewing includes rotary jaw action
12-18 Refining gross and fine motor skills, independent walking, climbing stairs, running, grasping and releasing with precision
Self feeding, grasps spoon with whole hand, 2-handed cup holding, drinking with 4-5 consecutive swallows, holding and tipping cup
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Stages of Development
• Homeostasis
• Attachment
• Separation and individuation
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Stages
Age Development
1-3 months Homeostasis * State regulation
* Neurophysiologic stability
2-6 months Attachment * “falling in love”
* Affective engagement and interaction
6-36 months
Separation and individuation
* Differentiation
* Behavioral organization and control
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Homeostasis
• Infant cycles through physical states
• Parent provides a safe and comfortable environment
• Reflex feeding transforms to self regulation of hunger
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Attachment
• Emotional/social interactions
• Parent reciprocates/engages
• Infant’s emotional and physical needs reinforced
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Separation
• Struggle for autonomy
• Parent supports autonomy and guides daily structure
• Emotional needs distinguished from physical needs
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Stage
Homeostasis
Birth to 3 months
Cues for feeding: arousal, crying, rooting, sucking
Caregiver responds to cues ( leads to self regulation.
Infant quiets to voice
Hunger-satiety pattern develops
Infant smile promotes interation
Pleasurable feeding experience--greater environmental interaction
Attachment:
3-6 months“Falling in love”
↑ reciprocity
Consistent cues, anticipation of feeding. Social pauses vs satiety of ? Burping, parents preferred feeder, attention seeking behavior
Separation I Individuation:
6-36 months
Responds to “no”, imitation, exploration play, follows simple directions, self independent feeding emerges, speech/language development,
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Emotion/Temperament
• Temperament theory categorizes enduring personality styles based on activity, adaptability, intensity, mood, persistence, distractibility, regularity, responsivity, approach/withdraw from novelty
Chess and Thomas 1970
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Temperament
• Easy: approaches novelty, positive mood, adaptable, regular, active, low intensity
• Slow to warm: withdraws from novelty, low mood, low activity, moderate to low intensity, cautious
• Difficult: withdrawing, low adaptability, high intensity, low regularity, negative mood
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Play, Learning, Exploration
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Feeding Difficulties
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Stage Feeding difficulty
Homeostasis Poor growth, stressful-unsatisfactory feeding, “colic”
Attachment Vomiting, diarrhea, poor weight gain, intensely conflicted or disengaged interactions
Separation-Individuation Food refusals
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Feeding Difficulties
• Complex problems caused by multiple factors within the lives of infants, children, and adults.– Medical/physical– Neurodevelopmental– Behavioral– Interact ional– Environmental– Psychosocial
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Why Baby Won’t Eat
• Case reports of FTT/inadequate intake without any identifiable etiology
– Tolia, et al
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• Problems established early in feeding persist into later life and generalize into other areas
• Ainsworth and Bell– feeding interactions in
early months were replicated in play interactions after 1st year
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• The Mother-Infant Feeding Relationship Across the First Year and the Development of Feeding Difficulties in Low-Risk Premature infants: Dalia Silberstein et al
– Infancy 14(5) 501-525 2009
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Silberstein
• N= 76
• Mother-Infant Observation 2-3 days prior to hospital discharge, 4 months corrected age, and 1 year corrected age
• Difficult vs non difficult feeders– Greater maternal gaze aversion, less
adaptability, less affectionate touch during play interactions, more intrusive at 1 year
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Factors to consider
• Medical
• Developmental
• Temperament
• Psychosocial
• Nutritional
• Environmental
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Feeding
• Delays in feeding skills
• feeding intolerance
• behavioral
• medical/physiological limitations
• other
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Feeding DifficultiesRelated to maturity, medical and
neurodevelopmental status
• State control• endurance• suck-swallow-breath coordination• sleep-wake cycles• cues and demand behavior• temperament• patterns of oral-motor development
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The Complexity of feeding problems in 700 infants and young children Presenting to a
Tertiary Care Institution• Rommel et al: J Ped Gastro and Nutrition,
July 2003
• Multidisciplinary Assessment catagorized feeding problems:– 86.1% medical– 61% oropharangeal dysfunction– 18.1% behavioral
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Rommel et al
• Medical/oral-motor – occurred more often <2 years of age
• Behavioral– occurred more often >2 years of age
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Rommel et al
• Single identified problem
– 26.7% medical– 5.2 % oral/motor– 5.4% behavioral
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Rommel et al
• Multifactorial– 48.5% oral/medical– 1.5% oral/behavioral– 5.2% medical behavioral