toddler distress and child weight status. An exploratory study

Appetite 57 (2011) 693–699

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Research report

Parent use of food to soothe infant/toddler distress and child weight status. An exploratory study§ Cynthia A. Stifter a,*, Stephanie Anzman-Frasca a, Leann L. Birch a, Kristin Voegtline b a b

Human Development and Family Studies, The Pennsylvania State University, University Park, PA 16802, USA Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA

A R T I C L E I N F O

A B S T R A C T

Article history: Received 18 April 2011 Received in revised form 24 July 2011 Accepted 16 August 2011 Available online 30 August 2011

The aim of the present study was to explore the parent feeding practice of using food to soothe infant/ toddler distress and its relationship to child weight status. Seventy eight families with infants and toddlers (43 males) ranging in age from 3 to 34 months (M = 14 mos, SD = 9 mos) completed a survey which included questions on their use of food to soothe, questionnaires on parent feeding practices, parenting self-efficacy, child temperament and child’s weight and length at the time of their last wellbaby visit. Results revealed the use of food to soothe to be a valid construct. In addition, mothers who used food to soothe rated themselves lower in parenting self-efficacy and their children higher in temperamental negativity. Analyses examining weight status as the outcome variable revealed that mothers who reported the use of food to soothe had heavier children, however, this relationship was stronger for children rated as high in temperamental negativity. ß 2011 Elsevier Ltd. All rights reserved.

Keywords: Infants Toddlers Parental feeding Soothing Child temperament Child weight status

Introduction Children under the age of 2 years have not been spared from the obesity epidemic in the United States. The most recent prevalence data revealed that 9.5% of infants are above the 95th percentile in weight (Ogden, Carroll, Curtin, Lamb, & Flegal, 2010). Without effective intervention, researchers predict that 50% of children in the US will be obese by 2030 (Wang, Beydoun, Liang, Caballero, & Kumanyika, 2008). Thus, innovative early prevention strategies are needed to halt this trend (Paul et al., 2009). Successful prevention efforts, however, require empirical support. Indeed, in an editorial in the Journal of Pediatrics (Zeller & Daniels, 2004), a call for basic research on the etiology of obesity was made. ‘‘More systematic inquiry into whether specific family/parent characteristics, childrearing practices, and parent beliefs contribute to the development of obesity in childhood and how these factors may interrelate with child characteristics is needed. . .. These types of data can provide information about the potentially modifiable child and family correlates of obesity that serves as barriers to successful obesity prevention and intervention efforts (p. 3).’’

§ This study was supported in part by a grant to the first author from the National Institutes of Digestive Diseases and Kidney (DK081512). The authors want to thank the families who participated in the study. * Corresponding author. E-mail address: [email protected] (C.A. Stifter).

0195-6663/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.appet.2011.08.013

One early modifiable risk factor for the development of childhood obesity is early parent feeding behaviors as parents ultimately control a young child’s food environment. The first choice that parents make about feeding is whether to breast or formula feed. In infancy, rapid weight gain is associated with greater energy intake (Ong et al., 2006) and it is well documented that energy intake and weight gain is greater in formula fed than breast fed infants (Owen, Martin, Whincup, Smith, & Cook, 2005). This difference may be due in part to differences in formula and breast feeding mothers’ attempts to control infants’ intake (Dewey, 1998; Dewey et al., 1995). Although the evidence confirms that breastfeeding reduces obesity risk, other evidence for ways in which parents’ feeding practices influence weight gain in infancy and toddlerhood is limited. Research with preschoolers, however, suggests that parental feeding practices influence children’s eating and weight. For example, parent feeding practices such as restrictive feeding and pressuring children to eat have the contradictory effect of increasing child eating and subsequent weight gain (Fisher & Birch, 1999; Galloway, Fiorito, Francis, & Birch, 2006). Birch and colleagues (Birch, Davison, & Fisher, 2003; Birch & Fisher, 1998) have argued that children tend to regulate energy intake in response to hunger and satiety cues, but that parents’ feeding practices may override appetite signals, and promote excessive intake and obesity. One manner in which parent feeding practices may render child appetite signals less effective is the use of food in non-eating contexts such as when they use of food to soothe their infants’ distress. Although there has been much speculation about the role

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of food in parent soothing of infant distress, there is a surprising paucity of empirical studies. It is very clear that food, especially that containing sugar, has an immediate effect on reducing infant distress (Blass & Watt, 1999). To date, only two studies have examined using food to soothe, and these were based on data from focus groups. The results of one focus group found middle income white mothers to endorse using food, particularly sweet and salty snacks, as a pacifier (Sherry et al., 2004). In another focus group, low-income mothers expressed beliefs that a bigger baby meant a healthier baby, and endorsed the use of food to soothe an infant’s distress or a toddler’s temper tantrum to shape behavior (Baughcum, Powers, & Johnson, 2001). Although not directly examining the impact of soothing infant distress with food, a study of mothers’ eating and feeding style and child BMI, found that mothers who reported eating themselves when distressed were more likely to feed their children when distressed (Wardle, Sanderson, Guthrie, Rapoport, & Plomin, 2002). Taken together, the results from these few studies suggest that parents endorse using food to soothe distress and may consider it appropriate. What is not clear is how often and under what circumstances parents elect to use food to soothe and what the consequences are for child weight. The primary goal of the present study was to examine the parenting practice of feeding to soothe. For the purposes of the present study feeding to soothe was defined as using any form of food in response to infant crying/fussing not attributed to hunger. In Zeller and Daniels’ (2004) call for research on the etiology of childhood obesity, they suggested that researchers consider not only parenting characteristics but also how these factors interact with child characteristics to influence the development of child weight status. Temperament or individual differences in emotional reactivity and regulation (Rothbart & Bates, 2006), a well-studied child characteristic, has been linked to child health and adjustment. With relation to weight status, studies have shown that ‘‘difficult’’ infants, those characterized by high negativity and low adaptability, were more likely to gain weight faster than less ‘‘difficult’’ infants (Carey, 1985; Carey, Hegvik, & McDevitt, 1988). More specifically, studies have documented those infants who were more anger-prone, rather than fear-prone, showed the fastest weight gain (Darlington & Wright, 2006; Slining, Adair, Goldman, Borja, & Bentley, 2009; Wells et al., 1997) or were more likely to be started on solids prior to 3 months, a risk factor for infant rapid weight gain (Wasser et al., 2011). This same temperament profile is evident in childhood predictions of adult weight; negative emotionality in childhood was the most robust predictor of adult BMI, even when controlling for variables related to BMI (PulkkiRaback, Elovianio, Kivimaki, Raitakari, & Keltikangas-Jarvinen, 2005). Of interest to the present investigation is a prospective study that followed children from birth to 10 years of age (Agras, Hammer, McNicholas, & Kraemer, 2004). The findings revealed that the relationship between parent BMI and child BMI was mediated by the temperament of the child, specifically high activity, anger and impulsivity. Importantly, children who had tantrums over food were more likely to be overweight; prompting the researchers to conclude that parents may use food to soothe children who are prone to unregulated anger. What the findings from the Agras study (2004) suggest is that child temperament may relate to childhood obesity either indirectly by evoking parenting responses or through interactions with parenting behaviors that may either buffer the negative effects or increase the risk for childhood overweight. Specific to the parent use of food to soothe, parents of a highly irritable infant may turn toward using food to soothe because of its effectiveness in calming distress. On the other hand, a parent whose baby is not overly reactive and calms easily would not have to resort to this soothing technique. Very little research, however, has examined

the influence of temperament on weight gain through its interaction with parent feeding behavior. Current study The goals of the present study were threefold; first we were interested in characterizing parent use of food to soothe their child’s distress. Toward this aim we surveyed parents of children ranging in age from 3 to 36 months and asked them about the frequency, effectiveness and circumstances under which they used food to soothe. We also assessed parent feeding behaviors and attitudes as a test of convergent and divergent validity of our assessment of feeding to soothe. Our second goal was to examine the relationship between parent use of food to soothe and child temperament. Parents completed a psychometrically sound questionnaire assessing infant/toddler temperament. We expected that parents would not use this soothing method with all infants but rather would be more likely to use food to soothe their infants who were more negatively reactive and less regulated. Finally, we were interested in determining whether parent use of food to soothe was related to child weight status and whether this is dependent upon their child’s temperament. Parents were asked to report on their child’s weight status taken at the last well-baby visit. To further understand parent use food to soothe and to inform our choice of covariates, we also examined possible correlates of this practice. As the only research to date has studied groups of mothers of differing income levels (Baughcum et al., 2001; Sherry et al., 2004), we tested whether family income was related to the use of food to soothe. Mother’s BMI was also tested as heavier mothers, particularly those who are emotional eaters, may be more likely to use food to soothe (Wardle et al., 2002). We also explored whether parenting selfefficacy may affect the choice of using food to soothe infant distress. Mothers who report low parenting self-efficacy may turn to using food to stop infant crying as they may not feel confident in their ability to appropriately and effectively soothe their infants. Finally, the child’s predominant feeding method, breastfeeding vs. formula feeding, was also examined. Research indicates that breastfeeding protects against the development of obesity (Owen et al., 2005), however, we had no expectation about its relation to feeding to soothe. Method Participants The sample comprised 100 parents (all mothers) recruited from a mailing to families residing in counties surrounding a Northeastern university (response rate 50%). Only those families that had complete data (N = 78) are reported here. Mothers averaged 32.6 years of age (SD = 10.0), the majority of whom (65%) completed at least 4 years of college. The BMI for mothers ranged from 18.6 to 39.9 (M = 26.0, SD = 5.15). Children (43 males) were white and ranged in age from 3 months to 34 months (M = 14.0, SD = 9.0). Family income was greater than $60,000 for half of the families (49%). Measures Baby’s Basic Needs Questionnaire (BBNQ). Developed specifically for this study, the BBNQ asked parents about the basic needs of their children including feeding, sleeping, crying and soothing. From this survey we obtained the following information: (1) parent use of food to soothe their child; (2) feeding history; and (3) infant/toddler weight and length. Parent use of food to

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Table 1 Items on questionnaire tapping the use of food to soothe infant distress. Item How How How How How How How How How How How How How a

a

often did you offer food or liquid to soothe your child? likely were you to use food to soothe in the grocery store? likely were you to use food to soothe in the doctor’s waiting room? likely were you to use food to soothe in church? likely were you to use food to soothe in the car? likely were you to use food to soothe when getting ready to leave? likely were you to use food to soothe when preparing foods? likely were you to use food to soothe when attending to another person? likely were you to use food to soothe when you are on the phone? likely were you to use food to soothe when your child wakes at night? likely were you to use food to soothe when you are stressed? likely were you to use food to soothe when you are tired? likely were you to use food to soothe when nothing else works?

Mean

SD

3.17 2.86 2.52 2.95 2.83 2.00 2.64 2.12 2.14 2.59 2.25 2.34 3.51

1.17 1.45 1.35 1.50 1.46 1.28 1.38 1.20 1.32 1.74 1.17 1.28 1.34

Rated on a 5-point scale.

soothe was assessed from 13 items on the BBNQ including how often they used food to soothe generally and how likely they were to use it during several different situations (1: never, 3: sometimes, and 5: often). The effectiveness of the use of food to soothe (1: does not work, 3: works about half the time, and 5: works all the time) was also assessed. These items can be seen in Table 1. Parents were also asked several questions about the predominant feeding method and whether or not they had breastfed their child. Because breastfeeding has been found to be a protective factor for infant rapid weight gain and childhood obesity, we created a measure that reflected whether or not the child was ever breastfed. Two groups were created based on whether mothers ever breastfed regardless of when they stopped (80%) or did not breastfeed their infants. Parents were also asked to report their child’s weight and length recorded at the last well-baby visit as well as the age of the child at that visit. This information, and the child’s sex, was used to calculate BMI-for-age z-scores using the World Health Organization (WHO) growth charts based on the recent recommendation to use these charts for children younger than 24 months (GrummerStrawn, Reinold, Krebs, & Centers for Disease Control and Prevention, 2010). At this age, the WHO growth charts depict longitudinal growth in optimal environments in six international locations; among the inclusion criteria were exclusive breastfeeding for 4 months, breastfeeding through age 1 year, and a high socioeconomic status. After age 24 months, the WHO growth charts are comparable to the CDC growth charts. To be consistent, the WHO growth charts were used for all children in the present study where the majority of the children were younger than 24 months. Height for children 24 months and older (n = 14) was coded as standing height; for all others, it was coded as a recumbent length measurement. Parenting Self-efficacy Questionnaire (Fish, Stifter, & Belsky, 1991). Mothers completed this 18-item questionnaire which assesses feelings of competence as a parent, the ability to meet the child’s needs, and feelings of the difficulty and need for support in the parenting role. Maternal responses to the 5-point scaled items were averaged with high scores reflecting stronger feelings of parenting self-efficacy (a = .83). Infant Behavior Questionnaire (IBQ)/Early Childhood Behavior Questionnaire (ECBQ) (Putnam, Gartstein, & Rothbart, 2006; Rothbart, 1981). Parent ratings of infant temperament were obtained using the IBQ (191 items) if their infant was between 3 and 18 months, and the ECBQ (201 items) if their child was between 18 and 36 months. Both questionnaires were developed by Rothbart and based on her developmental approach. Thus, both had similar factor structures: Negativity, Approach/Surgency, and Regulation/Effortful Control. The Negativity factor included items

assessing anger, fear, sadness and discomfort (IBQ a = .76; ECBQ a = .67). The Approach/Surgency factor tapped the child’s activity level, approach to novelty, impulsivity, and high intensity positive affect (a’s = .74, .72) whereas the Regulation/Effortful Control factor tapped the child’s soothability, attentional abilities, and inhibitory control (a’s = .54, .80). Infant Feeding Style Questionnaire (IFSQ) (Thompson et al., 2009). The IFSQ was designed to assess parental feeding practices. This parent-report measure consists of 5 subscales that tap parental control practices and attitudes (e.g., restriction, pressure, responsive, indulgence, and laissez faire) in child feeding. Only the beliefs scale was used in the present study. The restrictive subscale reflects the control of feeding and diet, e.g., ‘‘It’s important for the parent to decide how much an infant should eat’’ (a = .62). The pressure subscale includes finishing food, the use of cereal in a bottle, and feeding in response to crying, e.g., ‘‘It’s important that an infant finish all of the milk in his or her bottle’’ (a = .76). Responsive feeding comprises responsiveness to satiety and hunger cues and encouraging the child to eat, e.g., ‘‘It’s important that an infant be the one to set his or her own feeding schedule’’ (a = .45). The indulgence subscale reflects permissiveness around eating and using food to soothe, e.g., ‘‘It is okay for a toddler not to have regular meal – a toddler should eat whenever s/he is hungry’’ (a = .92) whereas the laissez faire subscale comprises lack of attention to the child’s eating and diet, e.g., ‘‘It’s okay for a toddler to eat without any encouragement or help’’ (a = .43). The subscales have demonstrated excellent reliability and validity. Although the IFSQ was validated on 3–20 month old infants/toddlers, all parents in the present study completed the IFSQ on their children who ranged in age from 3 to 34 months.

Table 2 Means, standard deviations and range of the study variables.

Family income (% $60k–$80k) Breastfed (% yes) Maternal BMI Maternal self-efficacya Food to soothea Child age – well baby Child age – survey Child Weight Statusc Child temperamentb Surgency Negativity Regulation/effortful control a b c

5 point scale. 7 point scale. BMI-for-age z score.

N

%

76 76 73 77 78 77 76 77

22 80

77 77 77

Mean

SD

Range

25.97 4.51 2.75 12.25 14.04 .48

5.15 .64 .82 7.74 9.01 1.97

18.64–39.85 2.78–5.50 1.05–4.60 2.00–26.00 2.6–33.6 5.04 to 10.65

4.96 3.35 4.94

.62 .78 .71

3.48–6.51 1.88–5.36 3.46–6.51

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696 Table 3 Intercorrelations among study variables. 2 Family characteristics 1. Family income 2. Breastfed 3. Maternal BMI 4. Maternal self-efficacy 5. Food to soothe Child characteristics 6. Child agea 7. Child Weight Status 8. Surgency 9. Negativity 10. Regulation/effortful control

.26

3

4 .20 .34

5 .04 .02 .04

6 .01 .15 .07 .29

7 .01 .15 .15 .10 .15

8

9

10

.32 .29 .11 .20 .07

.11 .01 .13 .23 .06

.25 .14 .03 .27 .34

.31 .10 .02 .40 .05

.11

.15 .18

.01 .22 .01

.38 .04 .38 .20

Note: bolded correlations are significant at the p < .05 a Age at time of survey.

Demographics. Information about the parents’ income was derived from the survey. Mother-reported weight and height were also obtained so as to calculate maternal BMI.

Correlates of feeding to soothe

The means, standard deviations, and range of all the study variables can be found in Table 2. Intercorrelations among the study variables can be found in Table 3.

To examine potential correlates of the use of food to soothe child distress we ran univariate and multivariate analyses. The simple correlations between feeding to soothe and those variables hypothesized to be related to this parenting practice – family income, maternal weight status (BMI), maternal self-efficacy, whether the child had ever been breastfed, and infant/toddler temperament, can be seen in Table 3. Only maternal parenting selfefficacy and child negativity were significantly related to the use of food to soothe. A multiple regression using the same variables we hypothesized to be related to food to soothe, as well as child age at the time of the survey, was conducted with the food to soothe composite as the dependent variable. The overall model was significant, F(8, 56) = 32.90, p < .01, with 29% of the variance explained. Two of the 8 predictors of feeding to soothe were significant (see Table 4). When all other variables were controlled, maternal self-efficacy and mother ratings of child negativity were related to the use of food to soothe. Mothers who reported low feelings of confidence in their parenting were more likely to use food to soothe as were mothers who rated their infants as high in temperamental negativity.

Parent use of food to soothe

Predicting infant weight status

As can be seen in Table 1 the frequency with which parents used food to soothe infant/toddler distress was moderate with mothers reporting, on average, that they used food to soothe ‘‘sometimes.’’ Among a list of specific situations under which mothers were more likely to use food to soothe, ‘‘when nothing else works’’ was the most highly endorsed situation. Perhaps, not surprising, when asked about specific contexts in which parents would opt to use food to soothe their child’s distress, mothers were more likely to endorse public situations such as when in a grocery store or church rather than when they were feeling stressed or busy with other activities. To reduce the number of analyses, a composite measure reflecting parent use of food to soothe was created by averaging the 5-pt. scaled responses to the 13 items (a = 86). Convergent/divergent validity. To examine whether feeding to soothe was related to other parental beliefs about feeding, we correlated our composite measure with the 5 subscales of the IFSQ. The results revealed some convergent validity but no divergent validity. Feeding to soothe was positively correlated with pressuring, r = .23, p < .05, and indulgent, r = .23, p < .05, styles of parent feeding, suggesting convergent validity. A trend also emerged between responsive feeding and feeding to soothe, r = .21, p < .08. Although negatively correlated, restrictive feeding, r = .18, which was expected to demonstrate divergent validity, was not significantly related to the use of food to soothe.

Our next goal was to examine whether feeding to soothe and infant temperament as well as their interaction were related to child weight status. In these three hierarchical models, one for each temperament factor, we included those factors that were significantly related to infant weight status as well as those related to the use of food to soothe. As can be seen in Table 3, only family income and breastfeeding were correlated with child weight and thus were entered as covariates in the first block. Due to its significant relation to feeding to soothe, maternal selfefficacy was also entered in the first block. And, although the calculation of child weight status controlled for age at the time of measurement (well-baby visit), the age of the child when the survey was completed was also entered as a covariate in the first block.1 Child temperament (negativity, surgency, and regulation), feeding to soothe and their interaction were entered in the second block. All variables were centered prior to conducting the analyses.

Procedure Approval was obtained for the current study from the Institutional Review Board. Surveys were mailed to families identified through birth announcements and a local data base as having a child between the ages of 3 and 36 months. Mailings contained a cover letter inviting families to participate in the study, a consent form, and a questionnaire packet. Parents were asked to sign the consent form and, using the enclosed self-addressed, stamped envelope, mail it along with the completed questionnaires. Families were paid $10 upon receipt of the completed questionnaire packet. Results

1 The age of the child was reported twice in the survey: the age of the child at the last well-baby visit when the child was weighed, and the age of the child when the survey was completed. Child age during the well-baby visit was used to create the child weight status scores. As there was significant variation in the ages of the child when parents completed the survey we used the child’s age at the time of the survey as a covariate in the analyses. The average difference between these two ages was approximately 2 months, M = 2.15, SD = 2.14.

[(Fig._1)TD$IG]

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Table 4 Predicting food to soothe. Variable Mother’s BMI Family income Mother’s self-efficacy Ever breastfed Child negativity Child surgency Child regulation Child age in months

B

SE B .01 .05 .36 .33 .31 .19 .02 .02

b

.02 .07 .17 .25 .13 .15 .17 .01

p .05 .09 .28 .17 .31 .15 .02 .21

.67 .50 .04* .20 .02* .24 .90 .14

R2 = .29. * p < .05.

Table 5 Negativity  food to soothe predicting child BMI z-scores. Variable

B

SE B

b

Step 1: Covariates related to child weight, food to soothe Family income .36 .16 .26 Ever breastfed .80 .57 .17 Child age in months .019 .024 .092 Mother self-efficacy .42 .35 .14 Step 2: Adding child negativity, food to soothe, and their interaction Family income .36 .16 .26 Ever breastfed .88 .54 .19 Child age in months .039 .023 .18 Mother self-efficacy .84 .35 .28 Food to soothe (FTS) 3.03 1.38 1.28 Negativity 2.69 1.26 1.06 FTS  negativity interaction 1.07 .41 2.31

p .0309 .1660 .4301 .2285 .0278 .1090 .1027 .0184 .0321 .0367 .0119

Final model, F = 3.92, p = .0014; R2 for Step 1 = .1510; R2 for Step 2 = .3101.

Negativity. The hierarchical multiple regression analysis with the temperament dimension of negativity and its interaction with food to soothe was significant, F = 3.92, p < .001, with an R2 of .31. As can be seen in Table 5, main effects for family income and maternal self-efficacy were revealed. Children from lower income families were heavier as were those children whose mothers reported low parenting self-efficacy. Main effects were also revealed for feeding to soothe and temperamental negativity but these effects were subsumed under a significant interaction effect. Fig. 1 displays this interaction. Post hoc analysis examining the simple slopes of the interaction at +1 SD and 1 SD of the mean of feeding to soothe found that at 1 SD the slope was not significant, t(61) = 1.19, p < .24. However, at +1 SD above the mean the slope was significant, t(61) = 2.76, p < .01. Among mothers who used food to soothe their children’s distress, highly negative children were heavier than children low on temperamental negativity.2 Surgency. The hierarchical multiple regression analysis with surgency and its interaction with food to soothe was significant, F = 2.40, p < .05, however, only family income was related to child weight status, b = .25, p < .05 in this model. Children in families with low income were more likely to be heavier than children in families with high incomes. Regulation/effortful control. The temperament dimension of regulation/effortful control and its interaction with food to soothe was examined in a hierarchical regression with family income, breastfed, maternal self-efficacy, child age entered in the first block. The model was significant, F = 2.55, p < .05. As with temperamental

2 As the range for our outcome variable suggested outliers we conducted several influence tests (e.g., Cook’s D, DFIT) and two outliers were consistently revealed. We re-ran the analyses with the two outliers removed. The model remained significant, F(7, 60) = 2.74, p < .02, but the interaction was reduced to a trend, t(1, 60) = 1.91, p = .06.

Fig. 1. The interaction between mother use of food to soothe and child temperamental negativity predicts child weight status.

surgency, only family income was related to child weight status, b = .27, p < .05. Children from families with lower incomes were heavier that children from families with higher incomes. Discussion One of the goals of the present study was to characterize the parent feeding practice of using food to soothe child distress and to examine potential concomitants of this method. Conceptualized as using any form of food in response to infant/toddler crying or fussing other than due to hunger, we assessed the use of food to soothe in a cross-sectional sample of mothers of infants and toddlers aged 3–34 months. Our findings revealed that feeding to soothe was employed occasionally, and was positively related to pressuring and indulgent feeding practices. These relationships suggest that the use of food to soothe is a valid construct. Mothers who reported using food to soothe their children’s distress were also more likely to report pressuring/overfeeding their child and indulging their child’s food requests. Taken together, it appears that mothers who endorse these feeding practices may be responding more to their own needs, e.g., reducing aversive crying, finishing a bottle, rather than attending to the needs of the child. That is, they may prefer taking the easiest route to child soothing rather than spending time diagnosing the source of their child’s distress or enacting other soothing techniques that may have a lower probability of success. Or, they may hold the belief that finishing a meal is more important than being sensitive to when the child is sated. As our survey did not assess the child’s food intake for mothers who report overfeeding, this interpretation should be treated with caution. However, our findings on the concomitants of parent use of food to soothe provide some support for this conclusion. As there is very little research on the use of food to soothe, we also examined several factors that we hypothesized may be related to this practice – maternal BMI, predominant early feeding method (breast vs. bottle), family income, parenting self-efficacy and child temperament. Our results showed that mothers who report the use of food to soothe were more likely to rate themselves as low on parenting self-efficacy. These mothers were also more likely to rate their infants and toddlers as high on temperamental negativity. Parenting self-efficacy characterizes parents who feel competent in their parenting role and the ability to effectively soothe their child’s distress is central to this role as well as to the formation of attachment (Leerkes & Crockenberg, 2002). Because they have little or no confidence in their ability to appropriately care for their

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child, mothers in the present study who rated themselves as low on self-efficacy may turn to using food to soothe as it quickly calms infant/toddler distress. Likewise, mothers with children who they perceived as more negative may use food to soothe because of its soothing effectiveness. In a recent study, mothers of toddlers high in emotional reactivity were more likely to feed them sweet drinks/food, leading the researchers to speculate that mothers may use these obesogenic foods because of their effectiveness in soothing distress (Vollrath, Tonstad, Rothbart, & Hampson, 2010). It is important to note that maternal self-efficacy was negatively related to child negativity such that mothers with low self-efficacy reported their children as more temperamentally negative. Thus, both of these factors may work independently or together to influence mothers to use this feeding/soothing practice. Our findings on child weight status suggest that this practice may have consequences for child health. The second goal of the present study was to explore whether parent use of food to soothe infant/toddler distress would be related to child weight status and the role child temperament played in this relationship. Our findings revealed that, indeed, both the use of food to soothe and child temperament were directly related to child weight. The other dimensions of temperament, surgency and regulation, were unrelated to child weight. Consistent with previous studies (Agras et al., 2004; Slining et al., 2009) children who were rated by mothers as more negatively reactive were heavier than children rated as less negative. Similarly, mothers who noted that they occasionally used food to soothe their child’s distress were also heavier. Importantly, the relationship between food to soothe and child weight was strongest for those children highest in temperamental negativity. Highly negative infants and toddlers whose mothers reported using food to soothe were heavier than low negative children whose mothers used food to soothe. This finding might best be explained by the diathesis/stress model (Belsky & Pluess, 2009) which proposes that some individuals, due to their biological or temperamental predisposition, are more vulnerable to the negative effects of an unfavorable environment. In the present case, the practice of using food to soothe distress is the environment that has a detrimental effect (increased child weight status) but its effect is limited to those infants and toddlers rated as negative in temperament. Thus, the use of food to soothe may be a risk factor for childhood obesity particularly when used with children who are high in negativity. How might the use of food to soothe increase the risk for overweight and childhood obesity? On possible mechanism may be through the child’s learned association of food with the reduction of crying. As feeding in early childhood is predominantly under the control of the parent, using food in circumstances unrelated to hunger and sustenance, may lead to children’s understanding that food has other ‘reward-like’ qualities. In deciding to eat, young children may learn to rely on external cues, such as the presence of food, or their own emotional distress, rather than relying on internal cues of hunger or satiety. This compromised ability to self-regulate their food intake may put them at risk for overweight. Indeed, studies of children’s eating in the absence of hunger indicate that emotional or external eating style, regardless of weight status, contributes to eating when not hungry in school-aged children (Fisher & Birch, 2002; Moens & Braet, 2007). Using food to soothe infant/toddler distress may also promote the association of food with emotional comfort, a characteristic of emotional eaters (Greeno & Wing, 1994; Schacter, Goldman, & Gordon, 1968) that is associated with obesity in adults. The current data also indicate that when food is not used to soothe a highly negative child then the risk for childhood obesity, suggested by the main effect for temperamental negativity, is reduced. It may be that these parents use other means for soothing, and persist with those methods rather than using food to reduce

crying/fussing. Several studies have shown vestibular and vocal soothing techniques to be effective in reducing infant crying at all levels of distress (Jahromi, Stifter, & Putnam, 2004). As this was a cross-sectional study the data must be interpreted with caution. The children in the present study ranged in age from 3 to 34 months, an age span during which much development occurs that may influence the use of feeding to soothe. For example, as infants are less regulated than toddlers mothers of infants may use food to soothe more often with their infants than mothers of toddlers. Our results, however, revealed age to be unrelated to our study variables with one exception (temperamental regulation). Longitudinal studies that track the development of both infant characteristics and parental use of food to soothe would be poised to address how the feeding/soothing practice may change as the child matures and develops new skills. Another limitation of the crosssectional design of the present study was the reliance on mother report for all the study variables. For example, mothers of heavier children may rate themselves as less competent as parents because their child is overweight. Likewise, mothers may perceive their overweight children as more demanding. Although several longitudinal studies have shown either early temperament or parent feeding practices to be a risk factor for rapid weight gain in infancy and childhood obesity, they did not consider how these factors may interact to predict weight gain/status. Future research is needed to determine the causal relationship between parent use of food to soothe, child temperament, and child overweight. Child weight was also reported by their mothers and not objectively measured. Longitudinal studies that assess parent use of food to soothe early in infancy and child weight status across early childhood using objective measures of weight and length would confirm the role of this feeding practice as a risk factor for childhood obesity. In summary, the findings of the present study provide preliminary evidence on the parent feeding practice of using food to soothe infant/toddler distress. Our assessment of this practice showed modest convergent validity and was related to both maternal self-efficacy and child temperament. Furthermore, the consequence for child health was demonstrated such that using food to soothe with highly negative infants and toddlers may result in a heavier child. Identifying modifiable factors in early life that influence children’s energy intake are critical to the development of childhood obesity prevention programs.

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