Introducing Hard-to-Like Foods to Infants and Toddlers: Mothers’ Perspectives and Children’s Experiences about Learning to Accept Novel Foods
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The period of complementary food introduction is increasingly conceived to be an important period for building lifelong food preferences. While the majority of young children consume vegetables and fruit during the introduction of complementary foods [1], vegetable intake is reported to fall when children begin to eat foods of the family table [2]. Food acceptance is influenced by multiple inputs, including (1) individual
child traits, (2) environmental inputs, including familial practices and environments, and (3) repeated opportunities for learning and interaction with new foods (Fig. 1) [3]. Previously conducted studies utilizing repeated exposure strategies have proven effective in positively influencing children’s acceptance of novel foods and, to a lesser extent, consumption of such foods [4, 5]. Thus, for many children, barriers to their intake of harder-to-like foods appear to be related to which foods are provided
and the persistence with which unaccepted foods continue to be offered, even when they are first rejected.
Through the Good Tastes Study, we have recently explored early experiences of the mother and child with offering a hard-to-like bitter green vegetable (kale). Our aim was to capture transactions during the complementary feeding period which could illuminate the nature of difficult feeding experiences from both mother and child perspectives.
Caregivers of infants and toddlers (n = 106; 6–24 months of age) were video-recorded offering up to 8 tastes of pureed kale. Trained researchers coded videos for (1) successful tastes, (2) positive (e.g., reaching for the spoon, playing with the food) and negative child behaviors (e.g., expelling the food, avoiding the spoon, crying), and (3) the avidity with which children accepted the kale offers. Caregivers were queried regarding their
Fig. 1. A 2-stage model of influences on the development of children’s vegetable preferences and consumption. Stage 1 reflects influences on children’s willingness to try vegetables. Stage 2 considers inputs on children’s vegetable consumption. SES, socioeconomic status. Original from Johnson [3].
perceptions of their child’s liking for the food and the likelihood that they would re-offer the food in the future (a proxy for caregiver persistence). A brief interview was conducted with each participant to gain insights into caregivers’ knowledge of repeated exposure, how they handle food rejections, and what influences their willingness to continue to offer a rejected food.
Children’s refusal increased across the infancy to toddler age span (p = 0.000). Toddlers exhibited more avoidant behaviors (p = 0.000) and a lower rate of acceptance (p = 0.000) than younger infants. Maternal perceptions of children’s liking for kale and their intentions to re-offer the kale were highly correlated (r = 0.63, p = 0.000). Moreover, the mothers’ perceptions of child liking and their intention to re-offer kale were negatively associated with child avoidant behaviors (p < 0.001); especially when the child expelled the kale (p < 0.000). In agreement with previous studies, caregivers’ intention to re-offer was highly related to the amounts children consumed and how avidly it was eaten. Thus, the more difficult the feeding, the less mothers intended to persist in offering the disliked food. Accomplishing the goals of getting children to eat and avoiding stressful feedings take priority over building food acceptance.
During interviews, the majority of mothers revealed knowledge of repeated exposure concepts, but intentions to persist in offering rejected foods differed substantially. Some reported a firm conviction to “never give up” on rejected foods stating children should “eat what we eat,” while others reported being influenced by their child’s resistance and food dislikes, and having a focus on ensuring their children eat enough. Mothers
suggested re-offering a rejected food after “a break.” Intervals for “breaks” varied from days to months to years.
Our findings suggest a “sweet spot” for the introduction of complementary foods that occurs between 6 and 12 months of age. Difficulties in child feeding during toddlerhood may benefit from promoting self feeding skills rather than the introduction of novel foods. Future research is needed to translate repeated exposure paradigms into practical methods that can assist caregivers to persist in offering difficult-to-like foods.
References
1. Roess AA, Jacquier EF, Catellier DJ, et al: Food consumption patterns of infants and toddlers: findings from the Feeding Infants and Toddlers Study (FITS) 2016. J Nutr 2018;148(suppl 3):1525S–1535S.
2. Duffy EW, Kay MC, Jacquier EF, et al: Trends in food consumption patterns of US infants and toddlers from Feeding Infants and Toddlers Studies (FITS) in 2002, 2008, 2016. Nutrients 2019;11:2807.
3. Johnson SL: Developmental and environmental influences on young children’s vegetable preferences and consumption. Adv Nutr 2016;7:220S–231S.
4. Ahern SM, Caton SJ, Blundell-Birtill P, Hetherington MM: The effects of repeated exposure and variety on vegetable intake in pre-school children. Appetite 2019;132:37–43.
5. Spill MK, Johns K, Callahan EH, et al: Repeated exposure to food and food acceptability in infants and toddlers: a systematic review. Am J Clin Nutr 2019;109(suppl 1):978S–989S.
perceptions of their child’s liking for the food and the likelihood that they would re-offer the food in the future (a proxy for caregiver persistence). A brief interview was conducted with each participant to gain insights into caregivers’ knowledge of repeated exposure, how they handle food rejections, and what influences their willingness to continue to offer a rejected food.
Children’s refusal increased across the infancy to toddler age span (p = 0.000). Toddlers exhibited more avoidant behaviors (p = 0.000) and a lower rate of acceptance (p = 0.000) than younger infants. Maternal perceptions of children’s liking for kale and their intentions to re-offer the kale were highly correlated (r = 0.63, p = 0.000). Moreover, the mothers’ perceptions of child liking and their intention to re-offer kale were negatively associated with child avoidant behaviors (p < 0.001); especially when the child expelled the kale (p < 0.000). In agreement with previous studies, caregivers’ intention to re-offer was highly related to the amounts children consumed and how avidly it was eaten. Thus, the more difficult the feeding, the less mothers intended to persist in offering the disliked food. Accomplishing the goals of getting children to eat and avoiding stressful feedings take priority over building food acceptance.
During interviews, the majority of mothers revealed knowledge of repeated exposure concepts, but intentions to persist in offering rejected foods differed substantially. Some reported a firm conviction to “never give up” on rejected foods stating children should “eat what we eat,” while others reported being influenced by their child’s resistance and food dislikes, and having a focus on ensuring their children eat enough. Mothers
suggested re-offering a rejected food after “a break.” Intervals for “breaks” varied from days to months to years.
Our findings suggest a “sweet spot” for the introduction of complementary foods that occurs between 6 and 12 months of age. Difficulties in child feeding during toddlerhood may benefit from promoting self feeding skills rather than the introduction of novel foods. Future research is needed to translate repeated exposure paradigms into practical methods that can assist caregivers to persist in offering difficult-to-like foods.
References
1. Roess AA, Jacquier EF, Catellier DJ, et al: Food consumption patterns of infants and toddlers: findings from the Feeding Infants and Toddlers Study (FITS) 2016. J Nutr 2018;148(suppl 3):1525S–1535S.
2. Duffy EW, Kay MC, Jacquier EF, et al: Trends in food consumption patterns of US infants and toddlers from Feeding Infants and Toddlers Studies (FITS) in 2002, 2008, 2016. Nutrients 2019;11:2807.
3. Johnson SL: Developmental and environmental influences on young children’s vegetable preferences and consumption. Adv Nutr 2016;7:220S–231S.
4. Ahern SM, Caton SJ, Blundell-Birtill P, Hetherington MM: The effects of repeated exposure and variety on vegetable intake in pre-school children. Appetite 2019;132:37–43.
5. Spill MK, Johns K, Callahan EH, et al: Repeated exposure to food and food acceptability in infants and toddlers: a systematic review. Am J Clin Nutr 2019;109(suppl 1):978S–989S.
Abstract
Children reportedly consume a variety of adequate vegetables during the introduction of complementary foods, and breastfeeding helps to facilitate child food acceptance. However, dietary intake of vegetables is reported to fall when children begin to eat foods of the family table. In laboratory settings, repeated exposure is effective in promoting children’s acceptance and consumption of novel foods. We have recently explored mother and child early experiences (from infancy to toddlerhood) with offering hard-to-like foods. Our findings suggest a “sweet spot” for food introduction and acceptance during the early complementary feeding period (6–12 months) with increasing variability in acceptance and negative child behaviors occurring during toddlerhood. When queried, most mothers are familiar with repeated exposure concepts, but their persistence in continuing to offer disliked foods differs. Some report they will “never give up” – a stance linked to health beliefs and that children should “eat what we eat.” Others seem more influenced by children’s resistance and food dislikes, and the amounts their child eat. The majority believe that children’s tastes change and that their child will accept rejected foods later. These mothers may reoffer a rejected food after “a break.” Opportunities exist to translate repeated exposure paradigms to practical methods mothers can successfully adopt in the home.Introduction
Some foods appear to be easier to like than others, and numerous influences take part to shape children’s food preferences and acceptance patterns. These influences include hardwired, genetic reactions to basic tastants, exposure to flavors through maternal influences, the natural course of children’s eating development, and family level influences. Children must learn to like foods, and which foods become accepted varies according to children’s opportunities, and the quality of said opportunities for interaction with foods and flavors. Often the foods that are most difficult to engage children to eat are the foods, like vegetables, that we most desire children to eat. Instilling children with a for these nutritious foods is vital for the development of healthy eating habits which, when carried through for a lifetime, are thought to reduce therisk of preventable chronic diseases [1]. Children’s early experiences with such foods, via repeated exposures which caregivers utilize to acquaint children with these foods, tips the balance towards or away from their acceptance. Thus, the complementary feeding period is viewed as a critical developmental period for establishing eating behaviors and food acceptance patterns that can last a lifetime [2].
Emergence of Children’s Food Preferences
Children are born with genetic predispositions to like certain tastes; sweetness is preferred at birth and even elicits responses in utero by the 2nd trimester [3]. Sweet tasting substances evoke positive facial reflexes associated with and interpreted as pleasure. This innate preference for sweetness is theorized to facilitate the consumption of foods that are safe, energy dense, and sometimes (as in the case of fruits) good sources of nutrients required for healthy growth. Other basic tastants, like bitterness and sourness, elicit negative facial reflexes like gapes, grimaces, and pursing of the lips. It should be noted, however, that these negative responses do not necessarily inhibit ingestion early in life [4]. Influences on children’s food preferences start early in life, beginning in utero through transmission of flavors from the maternal diet into amniotic fluid [4]. For the infant who consumes human milk, the experience of receiving flavor exposure continues as, again, aromatic compounds from the maternaldiet are transmitted to infants through breastfeeding, a veritable smorgasbord of flavor. Such flavor exposures have been noted to facilitate the transition to solid foods during complementary feeding and, later, to foods of the family table [3, 5, 6].
Early and repeated experiences with flavor are thought to positively influence infants to more readily accept foods offered during the complementary feeding period, beginning around 6 months of age [6–9]. Sullivan and Birch [7] reported that infants who had been breastfed more readily accepted a novel vegetable as a first food than did infants with a history of formula feeding. Further, infants exposed to bitter tastes in protein hydrolysate formula more readily accepted and consumed such formula, and the effects of early exposure to these flavor persisted into the preschool years [8, 10]. These “natural experiments” of flavor transmission demonstrate the effects of repeated flavor exposure on children’s acquisition of food acceptance patterns. Experimental studies employing repeated exposure have consistently confirmed that repetition, and the associative conditioning that occurs with exposure, are reliable paths towards increasing children’s preference and consumption of initially disliked or rejected flavors [11, 12]. While most of these studies demonstrate short-term increases in children’s preference and consumption, one longitudinal study has reported lasting effects of repeated exposure to both a target vegetable and vegetable variety on 6-year-old children’s intake of a target vegetable [13].
Zajonc’s [14] mere exposure theory, applied to food and eating, is the theoretical basis for these findings and posits that repeated positive interactions and experiences with novelty (whether food, music, or any other experience) result in familiarization and ultimate liking and acceptance. In the case of eating, exposure to novel foods and positive experiences with initially rejected foods leads to willingness to try the food and eventual consumption (Fig. 1). Multiple feeding trials conducted with infants and young children validate this theory, with younger infants responding more favorably than toddlers and preschoolers [10, 12]. One critical point is that repeated exposure increases willingness to try a target food before increases in consumption – a point often lost on caregivers who are more focused on increasing how much children eat of a given food [15]. Another potential influence on young children’s emerging food preferences is proposed to occur when flavors of liked foods are mixed with flavors of less liked or disliked foods: the principle of associative conditioning of a flavor preference. A number of studies have paired known (milk) [12] or liked (peaches)
[11] foods with vegetables and report improvements in consumption of the paired vegetables, and in the case of pairing with a sweet food, reductions in facial reactions of distaste. While improvements in infants’ acceptance occurred, it is difficult to disentangle the effects of associative conditioning of flavors from repeated exposure effects given that multiple exposures occurred alongside the pairings of target foods with liked flavors, and no mere exposure condition was included in study designs. That said, the appearance of blends of fruit and vegetable in commercially prepared infant foods has reinforced these findings for consumers [16].
Zajonc’s [14] mere exposure theory, applied to food and eating, is the theoretical basis for these findings and posits that repeated positive interactions and experiences with novelty (whether food, music, or any other experience) result in familiarization and ultimate liking and acceptance. In the case of eating, exposure to novel foods and positive experiences with initially rejected foods leads to willingness to try the food and eventual consumption (Fig. 1). Multiple feeding trials conducted with infants and young children validate this theory, with younger infants responding more favorably than toddlers and preschoolers [10, 12]. One critical point is that repeated exposure increases willingness to try a target food before increases in consumption – a point often lost on caregivers who are more focused on increasing how much children eat of a given food [15]. Another potential influence on young children’s emerging food preferences is proposed to occur when flavors of liked foods are mixed with flavors of less liked or disliked foods: the principle of associative conditioning of a flavor preference. A number of studies have paired known (milk) [12] or liked (peaches)
[11] foods with vegetables and report improvements in consumption of the paired vegetables, and in the case of pairing with a sweet food, reductions in facial reactions of distaste. While improvements in infants’ acceptance occurred, it is difficult to disentangle the effects of associative conditioning of flavors from repeated exposure effects given that multiple exposures occurred alongside the pairings of target foods with liked flavors, and no mere exposure condition was included in study designs. That said, the appearance of blends of fruit and vegetable in commercially prepared infant foods has reinforced these findings for consumers [16].
Developmental Influences on Children’s Food Acceptance
Anatomical [17] and social-emotional aspects of children’s development occur during infancy and toddlerhood which are associated with children’s development of eating behavior [9, 18–21]. Maturation of the oral motor cavity, with increasing capacity to consume and manipulate semisolid and solid boluses, occurs during the period of 4–6 months of age, and the first teeth begin to appear around 6–8 months of age. Teething both positively and negatively influences children’s food acceptance by (1) promoting the acceptance of more textured foods and (2) creating day-to-day challenges in children’s appetites and responses to eating. Children also begin to gain more volitional control in eating as they advance towards toddlerhood. Gross and fine motor milestones (e.g., palmar and pincer grasps) emerge during this period of child development coinciding with children’s desire and ability to begin self-feeding. During the complementary feeding period and on into toddlerhood, children’s receptive and expressive language increases quickly, and, when motivated, children can follow simple
directions and learn names of objects. During toddlerhood, food neophobia, or
fear of new foods, and food jags also begin to occur; the toddler’s growing desire
for autonomy can be expressed as food refusal and negatively affect feeding [22].
Concurrently, children’s energy needs for growth begin to slow, and the nexus
of reduction in appetite, burgeoning food refusal, increased motoric capacity,
and demands for autonomy can translate into heightened parental concern and confusion [9]. Feeding the toddler multiple times per day for meals and snacks can be a demanding, unrelenting parental role. For infants and toddlers, such experiences may provide opportunities to continue to develop self-regulation in response to novelty. Repeated exposure to aversive stimuli could contribute to a toddler’s ability to engage in a novel experience and may also facilitate the development of emotional aspects of self-regulation during eating [19, 23]. Responsive parenting and feeding help promote
the development of emotional, social, and cognitive development, and help young children learn self-regulation of eating [23, 24].
directions and learn names of objects. During toddlerhood, food neophobia, or
fear of new foods, and food jags also begin to occur; the toddler’s growing desire
for autonomy can be expressed as food refusal and negatively affect feeding [22].
Concurrently, children’s energy needs for growth begin to slow, and the nexus
of reduction in appetite, burgeoning food refusal, increased motoric capacity,
and demands for autonomy can translate into heightened parental concern and confusion [9]. Feeding the toddler multiple times per day for meals and snacks can be a demanding, unrelenting parental role. For infants and toddlers, such experiences may provide opportunities to continue to develop self-regulation in response to novelty. Repeated exposure to aversive stimuli could contribute to a toddler’s ability to engage in a novel experience and may also facilitate the development of emotional aspects of self-regulation during eating [19, 23]. Responsive parenting and feeding help promote
the development of emotional, social, and cognitive development, and help young children learn self-regulation of eating [23, 24].
Caregiver Influences on Children’s Emerging Self-Regulation
Self-regulation is a complex construct that involves the capacity to regulate behaviors,
cognitions, and emotions in the context of positive and negative situations. Self-regulation encompasses a broad array of processes, some of which relate to the development of eating behavior [25]. These processes include, but are not limited to, executive functioning, emotion regulation, effortful and reactive control, impulsivity, and delay of gratification [26]. Emotion regulation, one facet of children’s self-regulation, develops over the second and third years, and is related to changes in children’s growing cognitive and language abilities [25]. Spinrad et al. [27] suggested that caregiver responses to children’s positive and negative affect influence children’s budding emotional competence. Mothers’ reactions to situations which their children find to be challenging can contribute to socializing children’s emotional responses; positive or supporting responses help children to learn ways to regulate their states
of arousal. Other maternal responses, e.g., giving in to their children’s demands when children react negatively, may prevent children from developing strategies to cope with negative arousal or even lead to escalation of negative arousal [25]. In a longitudinal study, Spinrad et al. [27] reported that mothers more often responded to 18-month-old children’s negative affect (compared to positive affect); some using distraction, some giving in to the child’s wishes, and others questioning the validity of the child’s emotions (e.g., “why are you crying?”). At 30 months, these kinds of maternal responses were used less frequently, and the use of verbal explanation increased. Thus, as children’s cognitive and language abilities increased, mothers used more verbal explanations or reasoning. Of note, when mothers “gave in” and granted children’s wishes, or questioned the validity of their reactions when children were 18 months of age, their children continued to display greater negative affect (and lower emotional self-regulation) in response to disappointment at 30 months of age. These researchers suggest that when children are indulged during challenging moments, they are also
denied opportunities to learn self-regulation for similar future challenges.
cognitions, and emotions in the context of positive and negative situations. Self-regulation encompasses a broad array of processes, some of which relate to the development of eating behavior [25]. These processes include, but are not limited to, executive functioning, emotion regulation, effortful and reactive control, impulsivity, and delay of gratification [26]. Emotion regulation, one facet of children’s self-regulation, develops over the second and third years, and is related to changes in children’s growing cognitive and language abilities [25]. Spinrad et al. [27] suggested that caregiver responses to children’s positive and negative affect influence children’s budding emotional competence. Mothers’ reactions to situations which their children find to be challenging can contribute to socializing children’s emotional responses; positive or supporting responses help children to learn ways to regulate their states
of arousal. Other maternal responses, e.g., giving in to their children’s demands when children react negatively, may prevent children from developing strategies to cope with negative arousal or even lead to escalation of negative arousal [25]. In a longitudinal study, Spinrad et al. [27] reported that mothers more often responded to 18-month-old children’s negative affect (compared to positive affect); some using distraction, some giving in to the child’s wishes, and others questioning the validity of the child’s emotions (e.g., “why are you crying?”). At 30 months, these kinds of maternal responses were used less frequently, and the use of verbal explanation increased. Thus, as children’s cognitive and language abilities increased, mothers used more verbal explanations or reasoning. Of note, when mothers “gave in” and granted children’s wishes, or questioned the validity of their reactions when children were 18 months of age, their children continued to display greater negative affect (and lower emotional self-regulation) in response to disappointment at 30 months of age. These researchers suggest that when children are indulged during challenging moments, they are also
denied opportunities to learn self-regulation for similar future challenges.
Neophobia Emergence and Challenges
Applied to the child feeding context, we pose that caregiver responses to children’s negative reactions to a novel food could invoke the same pattern of interactions between children and their caregivers. For example, when children are introduced to a food that is disliked, and they exhibit negative affect, and consequently the caregiver withdraws that food and replaces it with a better-accepted food (in the name of getting the child to eat enough), the child’s rejecting behavior is reinforced by the offering of a more-preferred food. This scenario represents one pathway by which picky eating could emerge and be unintentionally reinforced. Alternatively, when children’s negative reactions are met with equanimity, and the food continues to be offered but expectations of consumption are limited, this offers an opportunity to the child to become familiar with the food and to learn to regulate their reactions to experiences with novel foods. In the Good Tastes Study, infants showed variability in their response to the taste of a bitter, novel vegetable, with some infants avidly accepting the food and
others grimacing, gaping, and crying in response to the taste (Fig. 2) [28]. However negative responses did not result in the youngest infants (< 12 months of age) refusing to accept another taste of the same vegetable. That children responded negatively but continued to accept the next bite suggests that young infants may respond reflexively to the visual cue of a spoon loaded with food coming towards them: opening their mouths to accept the bite. Toddlers (between 12 and 24 months of age) in the Good Tastes Study exhibited greater reactivity to the taste of the food, and those who showed negative reactions were more likely to reject subsequent offers.
Previously, it has been noted that infants who are breastfed receive exposure to a greater variety of flavors than infants who are formula fed, and these flavor experiences confer an advantage for the breastfed infant in accepting first foods.
others grimacing, gaping, and crying in response to the taste (Fig. 2) [28]. However negative responses did not result in the youngest infants (< 12 months of age) refusing to accept another taste of the same vegetable. That children responded negatively but continued to accept the next bite suggests that young infants may respond reflexively to the visual cue of a spoon loaded with food coming towards them: opening their mouths to accept the bite. Toddlers (between 12 and 24 months of age) in the Good Tastes Study exhibited greater reactivity to the taste of the food, and those who showed negative reactions were more likely to reject subsequent offers.
Previously, it has been noted that infants who are breastfed receive exposure to a greater variety of flavors than infants who are formula fed, and these flavor experiences confer an advantage for the breastfed infant in accepting first foods.
In our Good Tastes Study, nearly all of the infants had some breastfeeding experience, but to differing degrees (3 weeks to 21 months), which could partially explain younger infants’ willingness to accept all bites of the novel food. However, highly significant effects were noted for child age; up to 12 months of age, while children displayed varying levels of resistance to offers of the food, no children ultimately rejected taking bites of the novel food (n = 46; 96% of whom had breastfeeding experience). Between 12 and 18 months, 47% (n = 40) rejected some bites of the food, and for children 18 months or older, 75% (n = 20) rejected some bites; all of these children had breastfeeding experience. Our findings support the notion that there is an age-related “sweet spot” or sensitive period for the introduction of difficult-to-like foods. Infants younger than 12 months of age may have a more reflexive response and open their mouth in response to the visual stimulus of food coming towards them. Previous research has reported that as high as 90% of novel foods are accepted at the start of complementary feeding, though fruits and vegetables were less accepted [29]. In the
case of vegetables, the earlier in the weaning period (from 4 to 6 months) that they were introduced, the better their acceptance by infants. Our findings support the notion that early on complementary feeding is a window of opportunity to introduce dietary variety [9, 12].
By the time that children reach toddlerhood, they exhibit greater motoric control, which can result in the ability and desire to self-feed. The efficiency of self-feeding improves with practice, but toddlers concurrently display a greater ability to reject foods by turning away their head, by intercepting the spoon, by throwing food, and often accompanied by outraged shrieks of “no”! In the Good Tastes Study, coding of video-recorded mother-child interactions during the offering of a bitter green vegetable revealed increases in negative child behaviors (crying, turning the head, swatting the spoon, and sometimes tantrums) in toddlers compared to younger infants [30]. The beginnings of food neophobia (rejection of a novel food) start to be displayed at around 15 months of age. Thus, we suggest that neophobia begins to emerge before 24 months of age,
perhaps at the developmental time point when children begin to demand more autonomy and when food acceptance transitions from the reflexive eating behaviors
of infancy on towards the emerging capacity for self-feeding and selfcontrol [20]. Toddlers’ increasing displays and desire for autonomy can thus result in more challenges and greater intensity of reaction, and, as noted by Spinrad et al. [27], they elicit varying maternal responses.
case of vegetables, the earlier in the weaning period (from 4 to 6 months) that they were introduced, the better their acceptance by infants. Our findings support the notion that early on complementary feeding is a window of opportunity to introduce dietary variety [9, 12].
By the time that children reach toddlerhood, they exhibit greater motoric control, which can result in the ability and desire to self-feed. The efficiency of self-feeding improves with practice, but toddlers concurrently display a greater ability to reject foods by turning away their head, by intercepting the spoon, by throwing food, and often accompanied by outraged shrieks of “no”! In the Good Tastes Study, coding of video-recorded mother-child interactions during the offering of a bitter green vegetable revealed increases in negative child behaviors (crying, turning the head, swatting the spoon, and sometimes tantrums) in toddlers compared to younger infants [30]. The beginnings of food neophobia (rejection of a novel food) start to be displayed at around 15 months of age. Thus, we suggest that neophobia begins to emerge before 24 months of age,
perhaps at the developmental time point when children begin to demand more autonomy and when food acceptance transitions from the reflexive eating behaviors
of infancy on towards the emerging capacity for self-feeding and selfcontrol [20]. Toddlers’ increasing displays and desire for autonomy can thus result in more challenges and greater intensity of reaction, and, as noted by Spinrad et al. [27], they elicit varying maternal responses.
How Do Caregivers Make Decisions Related to Feeding Persistence?
We recently conducted a survey, using snowball sampling techniques through online platforms (e.g., university LISTSERVS, NextDoor, Facebook, and mothers’ groups), with the specific research question of asking mothers (n = 219, 93% white, 80% income USD > 60,000) how many times they offer a new food to their young children (6 months to 5 years of age; mean age 30.7 ± 18.7 months), and how they make this determination. Caregivers most often stated that they would introduce a new food 3–5 times before deciding whether or not their child liked it, though 30% stated they would go > 10 times before moving on. Of those who related that they would, eventually, go back and re-offer this food to their child (75%), mothers reported that they would wait an average of days (27%), to weeks (44%), to months (19%), or even 6 months to years (6%). Several mothers stated it would be when they offered that food to the rest of the family (4%). About one-third of mothers stated they would re-offer the food 3–5 times, and an equal number said they would offer the food 10–15 times; a relatively high number (20%) endorsed that they would offer the food > 20 times and up to 1,000,000 times. This latter group is clearly a set of mothers who place importance on their children learning to eat vegetables.
Mothers conveyed that they depend on observations of children’s behaviors during eating to determine whether to continue offering a food to their child. Reasons stated for deciding to quit offering the food, at least for the moment, were obvious signs of child dislike (refusing to take a bite or throwing the food), gagging, crying, and tantrums, negative facial reactions, and spitting out the food. Mothers interpreted negative facial reactions and behaviors as a signal to stop offering the food or to take a break and re-offer the food at a later time. However, facial reactions such as grimacing or gaping in younger infants do not necessarily result in children declining to consume additional bites [11, 29]. In stead of indicating absolute rejection, these could be reflexive responses to novel tastes [3]. It may be appropriate to encourage mothers to persist in the face of initial negative facial responses and spitting out of foods that are unfamiliar if
these responses stop short of children crying, gagging, or showing strong displeasure.
Mothers’ stated feeding priorities included getting children to eat (enough), good nutrition, and exposure to a healthy diet, the child’s satisfaction both with specific foods served at an eating occasion and a good relationship with food generally, satisfying the child’s energy needs and avoiding mood swings associated with hunger, and promoting children’s acceptance of a wide variety of foods from different cultures, thus preventing their children from becoming picky eaters.
Our findings echo those of Carruth et al. [31] published in 1998, who reported decades ago that mothers’ intentions to re-offer rejected foods varies widely. While more mothers in the recent study indicated that they would re-offer a food a sufficient number of exposures to facilitate acceptance, the time period over which they would do so also varied from days, to months, and even years. A gap in knowledge regarding repeated exposure methods is illuminated by these findings: the optimal interval across which exposures can be offered has not been explored fully by researchers and varies dramatically in caregiver practice. Further, more research is necessary to determine whether early acceptance (during complementary feeding) is associated with reductions in picky eating or food neophobia. When asked about their emotions and reactions when their children rejected a food, most mothers from our survey reported they were surprisingly indifferent. Of those who stated frustration or sadness, these emotions were most often related to wastes of time, money, and food, or that their child would miss out on the healthfulness of the food rather than disappointment that the child had not enjoyed the food.
Mothers conveyed that they depend on observations of children’s behaviors during eating to determine whether to continue offering a food to their child. Reasons stated for deciding to quit offering the food, at least for the moment, were obvious signs of child dislike (refusing to take a bite or throwing the food), gagging, crying, and tantrums, negative facial reactions, and spitting out the food. Mothers interpreted negative facial reactions and behaviors as a signal to stop offering the food or to take a break and re-offer the food at a later time. However, facial reactions such as grimacing or gaping in younger infants do not necessarily result in children declining to consume additional bites [11, 29]. In stead of indicating absolute rejection, these could be reflexive responses to novel tastes [3]. It may be appropriate to encourage mothers to persist in the face of initial negative facial responses and spitting out of foods that are unfamiliar if
these responses stop short of children crying, gagging, or showing strong displeasure.
Mothers’ stated feeding priorities included getting children to eat (enough), good nutrition, and exposure to a healthy diet, the child’s satisfaction both with specific foods served at an eating occasion and a good relationship with food generally, satisfying the child’s energy needs and avoiding mood swings associated with hunger, and promoting children’s acceptance of a wide variety of foods from different cultures, thus preventing their children from becoming picky eaters.
Our findings echo those of Carruth et al. [31] published in 1998, who reported decades ago that mothers’ intentions to re-offer rejected foods varies widely. While more mothers in the recent study indicated that they would re-offer a food a sufficient number of exposures to facilitate acceptance, the time period over which they would do so also varied from days, to months, and even years. A gap in knowledge regarding repeated exposure methods is illuminated by these findings: the optimal interval across which exposures can be offered has not been explored fully by researchers and varies dramatically in caregiver practice. Further, more research is necessary to determine whether early acceptance (during complementary feeding) is associated with reductions in picky eating or food neophobia. When asked about their emotions and reactions when their children rejected a food, most mothers from our survey reported they were surprisingly indifferent. Of those who stated frustration or sadness, these emotions were most often related to wastes of time, money, and food, or that their child would miss out on the healthfulness of the food rather than disappointment that the child had not enjoyed the food.
Caregiver Feeding Priorities and the Influence on Maternal Persistence in Offering Difficult-to-Like Foods
From the findings of our survey, as well as those of previous studies [32], what emerges is that mothers have competing priorities for feeding their young infants and toddlers. Goals for nutrition, health, and eating collide with concerns about whether their child is eating enough [33, 34] to sustain optimal growth and development. Ultimately, what appears to count most for mothers is how much children consume, and how easily this happens during feeding [6], ensuring that their children enjoy eating. Mothers attend to children’s facial responses to foods in the early complementary feeding period, and what seems, understandably, to dictate mothers’ responses is how difficult it is to accomplish the end goal of getting their child to eat. By the time children reach toddlerhood feeding challenges often escalate, and the multiple-times-per-day task of feeding their child, who is increasingly demanding autonomy (though not necessarily
ready for it), can become less and less rewarding. Thus, persisting to offer foods
that may rate highly for nutrition and health, but that make the feeding and parenting
experience consistently onerous, can be a tall order, whereas alternative strategies like “taking a break” from the food or coercive and pressuring feeding practices may yield better short-term outcomes for how much children consume [20].
Conclusions
It would seem that future research would best be oriented towards methods to help caregivers learn to persist in offering difficult-to-like foods until they reap the rewards of children’s acceptance of these foods, instilling confidence and trust in the process of repeated exposure and the concept that children generally will eat enough to meet their energy needs when offered a balanced, nutritious diet. Additional studies should be undertaken to determine whether taking “breaks” in offering previously rejected foods improves or detracts from building liking, and to determine whether an optimal interval exists during which exposures should take place to build lasting improvements in acceptance for difficult-to-like foods.
Caregivers desire information and strategies to help their children participate in family meals and to learn to have a healthful relationship with food and eating [35]. Promoting children’s autonomy and their development of self-regulation skills may help with challenging mealtimes during the toddler period.
Acknowledgments
We would like to acknowledge the efforts of Haley Lucitt, MSPH, who designed and administered the Good Tastes Survey.
Conflict of Interest Statement
The work presented herein was funded by an investigator-initiated research grant from
the Sugar Association. Both authors received salary and research support from this grant. The funder has not participated in, nor been privy to, study design, data analyses, or the writing of this publication. The authors have no additional conflicts to report.
References
1. Schulze MB, Martínez-González MA, Fung TT, et al: Food based dietary patterns and chronic disease prevention. BMJ 2018; 361:k2396.
2 Craigie AM, Lake AA, Kelly SA, et al: Tracking of obesity-related behaviours from childhood to adulthood: a systematic review. Maturitas 2011; 70: 266–284.
3. Nicklaus S: 13 – Relationships between early flavor exposure, and food acceptability and neophobia; in Etiévant P, Guichard E, Salles C, Voilley A (eds): Flavor: From Food to Behaviors, Wellbeing and Health. Duxford, Woodhead Publishing, 2016, pp 293–311.
4. Mennella JA, Nicklaus S, Jagolino AL, Yourshaw LM: Variety is the spice of life: strategies for promoting fruit and vegetable acceptance during infancy. Physiol Behav 2008; 94: 29–38.
5. Hausner H, Nicklaus S, Issanchou S, et al: Breastfeeding facilitates acceptance of a novel dietary flavour compound. e-SPEN 2009; 4:e231–e238.
6. Gerrish CJ, Mennella JA: Flavor variety enhances food acceptance in formula-fed infants. Am J Clin Nutr 2001; 73: 1080–1085.
7. Sullivan SA, Birch LL: Infant dietary experience and acceptance of solid foods. Pediatrics 1994; 93: 271–277.
8. Mennella JA, Griffin CE, Beauchamp GK: Flavor programming during infancy. Pediatrics 2004; 113: 840–845.
9. Schwartz C, Vandenberghe-Descamps M, Sulmont- Rossé C, et al: Behavioral and physiological determinants of food choice and consumption at sensitive periods of the life span, a focus on infants and elderly. Innov Food Sci Emerg Technol 2018; 46: 91–106.
10. Anzman-Frasca S, Ehrenberg S: Learning to like: roles of repeated exposure and other types of learning; in Lumeng JC, Fisher JO (eds): Pediatric Food Preferences and Eating Behaviors. London, Academic Press, 2018, pp 35–52.
11. Forestell CA, Mennella JA: Early determinants of fruit and vegetable acceptance. Pediatrics 2007; 120: 1247–1254.
12. Hetherington MM, Schwartz C, Madrelle J, et al: A step-by-step introduction to vegetables at the beginning of complementary feeding. The effects of early and repeated exposure. Appetite 2015; 84: 280–290.
13 Maier-Nöth A, Schaal B, Leathwood P, Issanchou S: The lasting influences of early food-related variety experience: a longitudinal study of vegetable acceptance from 5 months to 6 years in two populations. PLoS One 2016; 11:e0151356.
14. Zajonc RB: Attitudinal effects of mere exposure. J Pers Soc Psychol 1968; 9: 1.
15. Johnson SL, Ryan SM, Kroehl M, et al: A longitudinal intervention to improve young children’s liking and consumption of new foods: findings from the Colorado LEAP study. Int J Behav Nutr Phys Act 2019; 16: 49.
16. Moding KJ, Ferrante MJ, Bellows LL, et al: Variety and content of commercial infant and toddler vegetable products manufactured and sold in the United States. Am J Clin Nutr 2018; 107: 576–583.
17. Gee BM, Engle J, Parker C, et al: Frequency and duration of developmental fine motor patterns in infants and toddlers: a pilot cohort study. Ann Int Occup Ther 2019; 3: 21–28.
18. Johnson SL, Hayes JE: Developmental readiness, caregiver and child feeding behaviors, and sensory science as a framework for feeding young children. Nutr Today 2017; 52(suppl):S30–S40.
19. Birch LL, Doub AE: Learning to eat: birth to age 2 years. Am J Clin Nutr 2014; 99: 723S–728S.
20. Cole NC, An R, Lee S-Y, Donovan SM: Correlates of picky eating and food neophobia in young children: a systematic review and meta-analysis. Nutr Rev 2017; 75: 516–532.
21. Carruth BR, Ziegler PJ, Gordon A, Hendricks K: Developmental milestones and self-feeding behaviors in infants and toddlers. J Am Diet Assoc 2004; 104: 51–56.
22. Johnson SL, Moding KJ, Bellows LL: Children’s challenging eating behaviors: picky eating, food neophobia, and food selectivity; in Lumeng JC, Fisher JO (eds): Pediatric Food Preferences and Eating Behaviors. London, Academic Press, 2018, pp 73–92.
23. Stoeckel LE, Birch LL, Heatherton T, et al: Psychological and neural contributions to appetite self-regulation. Obesity 2017; 25(S1):S17–S25.
24. Black MM, Aboud FE: Responsive feeding is embedded in a theoretical framework of responsive parenting. J Nutr 2011; 141: 490–494.
25. Kopp CB: Regulation of distress and negative emotions: a developmental view. Dev Psychol 1989; 25: 343.
26. Baker S, Morawska A, Mitchell A: Promoting children’s healthy habits through self-regulation via parenting. Clin Child Family Psychol Rev 2019; 22: 52–62.
27. Spinrad TL, Stifter CA, Donelan-McCall N, Turner L: Mothers’ regulation strategies in response to toddlers’ affect: links to later emotion self-regulation. Soc Dev 2004; 13: 40–55.
28. Johnson S, Moding K, Hayes JE, et al: The Good Tastes Study: infants’ and toddlers’ acceptance of a familiar food and novel green bitter vegetable purees. American Society for Nutrition (ASN) Annual Meeting 2018.
29. Schwartz C, Issanchou S, Nicklaus S: Developmental changes in the acceptance of the five basic tastes in the first year of life. Br J Nutr 2009; 102: 1375–1385.
30. Johnson S, Moding K, Flesher A, et al: The Good Tastes Study: relations between children’s eating behaviors and caregivers’ intentions to persist in offering difficult-to-like foods (OR03-02-19). Curr Dev Nutr 2019; 3(suppl 1).
31. Carruth BR, Skinner J, Houck K, et al: The phenomenon of “picky eater”: a behavioral marker in eating patterns of toddlers. J Am Coll Nutr 1998; 17: 180–186.
32. Holley CE, Farrow C, Haycraft E: Investigating offering of vegetables by caregivers of preschool age children. Child Care Health Dev 2017; 43: 240–249.
33. McNally J, Hugh-Jones S, Hetherington MM: “An invisible map” – maternal perceptions of hunger, satiation and “enough” in the context of baby led and traditional complementary feeding practices. Appetite 2020; 148: 104608.
34. Spill MK, Callahan EH, Shapiro MJ, et al: Caregiver feeding practices and child weight outcomes: a systematic review. Am J Clin Nutr 2019; 109(suppl 7): 990S–1002S.
35. Hepworth A, Brick T, Small M: Exploring parents’ satisfaction with infant and toddler feeding information: a repeated-measures analysis of information need and acquisition characteristics (P17-006-19). Curr Dev Nutr 2019; 3(suppl 1):nzz038.P17-006-19.
36. Johnson SL: Developmental and environmental influences on young children’s vegetable preferences and consumption. Adv Nutr 2016; 7: 220S– 231S.
ready for it), can become less and less rewarding. Thus, persisting to offer foods
that may rate highly for nutrition and health, but that make the feeding and parenting
experience consistently onerous, can be a tall order, whereas alternative strategies like “taking a break” from the food or coercive and pressuring feeding practices may yield better short-term outcomes for how much children consume [20].
Conclusions
It would seem that future research would best be oriented towards methods to help caregivers learn to persist in offering difficult-to-like foods until they reap the rewards of children’s acceptance of these foods, instilling confidence and trust in the process of repeated exposure and the concept that children generally will eat enough to meet their energy needs when offered a balanced, nutritious diet. Additional studies should be undertaken to determine whether taking “breaks” in offering previously rejected foods improves or detracts from building liking, and to determine whether an optimal interval exists during which exposures should take place to build lasting improvements in acceptance for difficult-to-like foods.
Caregivers desire information and strategies to help their children participate in family meals and to learn to have a healthful relationship with food and eating [35]. Promoting children’s autonomy and their development of self-regulation skills may help with challenging mealtimes during the toddler period.
Acknowledgments
We would like to acknowledge the efforts of Haley Lucitt, MSPH, who designed and administered the Good Tastes Survey.
Conflict of Interest Statement
The work presented herein was funded by an investigator-initiated research grant from
the Sugar Association. Both authors received salary and research support from this grant. The funder has not participated in, nor been privy to, study design, data analyses, or the writing of this publication. The authors have no additional conflicts to report.
References
1. Schulze MB, Martínez-González MA, Fung TT, et al: Food based dietary patterns and chronic disease prevention. BMJ 2018; 361:k2396.
2 Craigie AM, Lake AA, Kelly SA, et al: Tracking of obesity-related behaviours from childhood to adulthood: a systematic review. Maturitas 2011; 70: 266–284.
3. Nicklaus S: 13 – Relationships between early flavor exposure, and food acceptability and neophobia; in Etiévant P, Guichard E, Salles C, Voilley A (eds): Flavor: From Food to Behaviors, Wellbeing and Health. Duxford, Woodhead Publishing, 2016, pp 293–311.
4. Mennella JA, Nicklaus S, Jagolino AL, Yourshaw LM: Variety is the spice of life: strategies for promoting fruit and vegetable acceptance during infancy. Physiol Behav 2008; 94: 29–38.
5. Hausner H, Nicklaus S, Issanchou S, et al: Breastfeeding facilitates acceptance of a novel dietary flavour compound. e-SPEN 2009; 4:e231–e238.
6. Gerrish CJ, Mennella JA: Flavor variety enhances food acceptance in formula-fed infants. Am J Clin Nutr 2001; 73: 1080–1085.
7. Sullivan SA, Birch LL: Infant dietary experience and acceptance of solid foods. Pediatrics 1994; 93: 271–277.
8. Mennella JA, Griffin CE, Beauchamp GK: Flavor programming during infancy. Pediatrics 2004; 113: 840–845.
9. Schwartz C, Vandenberghe-Descamps M, Sulmont- Rossé C, et al: Behavioral and physiological determinants of food choice and consumption at sensitive periods of the life span, a focus on infants and elderly. Innov Food Sci Emerg Technol 2018; 46: 91–106.
10. Anzman-Frasca S, Ehrenberg S: Learning to like: roles of repeated exposure and other types of learning; in Lumeng JC, Fisher JO (eds): Pediatric Food Preferences and Eating Behaviors. London, Academic Press, 2018, pp 35–52.
11. Forestell CA, Mennella JA: Early determinants of fruit and vegetable acceptance. Pediatrics 2007; 120: 1247–1254.
12. Hetherington MM, Schwartz C, Madrelle J, et al: A step-by-step introduction to vegetables at the beginning of complementary feeding. The effects of early and repeated exposure. Appetite 2015; 84: 280–290.
13 Maier-Nöth A, Schaal B, Leathwood P, Issanchou S: The lasting influences of early food-related variety experience: a longitudinal study of vegetable acceptance from 5 months to 6 years in two populations. PLoS One 2016; 11:e0151356.
14. Zajonc RB: Attitudinal effects of mere exposure. J Pers Soc Psychol 1968; 9: 1.
15. Johnson SL, Ryan SM, Kroehl M, et al: A longitudinal intervention to improve young children’s liking and consumption of new foods: findings from the Colorado LEAP study. Int J Behav Nutr Phys Act 2019; 16: 49.
16. Moding KJ, Ferrante MJ, Bellows LL, et al: Variety and content of commercial infant and toddler vegetable products manufactured and sold in the United States. Am J Clin Nutr 2018; 107: 576–583.
17. Gee BM, Engle J, Parker C, et al: Frequency and duration of developmental fine motor patterns in infants and toddlers: a pilot cohort study. Ann Int Occup Ther 2019; 3: 21–28.
18. Johnson SL, Hayes JE: Developmental readiness, caregiver and child feeding behaviors, and sensory science as a framework for feeding young children. Nutr Today 2017; 52(suppl):S30–S40.
19. Birch LL, Doub AE: Learning to eat: birth to age 2 years. Am J Clin Nutr 2014; 99: 723S–728S.
20. Cole NC, An R, Lee S-Y, Donovan SM: Correlates of picky eating and food neophobia in young children: a systematic review and meta-analysis. Nutr Rev 2017; 75: 516–532.
21. Carruth BR, Ziegler PJ, Gordon A, Hendricks K: Developmental milestones and self-feeding behaviors in infants and toddlers. J Am Diet Assoc 2004; 104: 51–56.
22. Johnson SL, Moding KJ, Bellows LL: Children’s challenging eating behaviors: picky eating, food neophobia, and food selectivity; in Lumeng JC, Fisher JO (eds): Pediatric Food Preferences and Eating Behaviors. London, Academic Press, 2018, pp 73–92.
23. Stoeckel LE, Birch LL, Heatherton T, et al: Psychological and neural contributions to appetite self-regulation. Obesity 2017; 25(S1):S17–S25.
24. Black MM, Aboud FE: Responsive feeding is embedded in a theoretical framework of responsive parenting. J Nutr 2011; 141: 490–494.
25. Kopp CB: Regulation of distress and negative emotions: a developmental view. Dev Psychol 1989; 25: 343.
26. Baker S, Morawska A, Mitchell A: Promoting children’s healthy habits through self-regulation via parenting. Clin Child Family Psychol Rev 2019; 22: 52–62.
27. Spinrad TL, Stifter CA, Donelan-McCall N, Turner L: Mothers’ regulation strategies in response to toddlers’ affect: links to later emotion self-regulation. Soc Dev 2004; 13: 40–55.
28. Johnson S, Moding K, Hayes JE, et al: The Good Tastes Study: infants’ and toddlers’ acceptance of a familiar food and novel green bitter vegetable purees. American Society for Nutrition (ASN) Annual Meeting 2018.
29. Schwartz C, Issanchou S, Nicklaus S: Developmental changes in the acceptance of the five basic tastes in the first year of life. Br J Nutr 2009; 102: 1375–1385.
30. Johnson S, Moding K, Flesher A, et al: The Good Tastes Study: relations between children’s eating behaviors and caregivers’ intentions to persist in offering difficult-to-like foods (OR03-02-19). Curr Dev Nutr 2019; 3(suppl 1).
31. Carruth BR, Skinner J, Houck K, et al: The phenomenon of “picky eater”: a behavioral marker in eating patterns of toddlers. J Am Coll Nutr 1998; 17: 180–186.
32. Holley CE, Farrow C, Haycraft E: Investigating offering of vegetables by caregivers of preschool age children. Child Care Health Dev 2017; 43: 240–249.
33. McNally J, Hugh-Jones S, Hetherington MM: “An invisible map” – maternal perceptions of hunger, satiation and “enough” in the context of baby led and traditional complementary feeding practices. Appetite 2020; 148: 104608.
34. Spill MK, Callahan EH, Shapiro MJ, et al: Caregiver feeding practices and child weight outcomes: a systematic review. Am J Clin Nutr 2019; 109(suppl 7): 990S–1002S.
35. Hepworth A, Brick T, Small M: Exploring parents’ satisfaction with infant and toddler feeding information: a repeated-measures analysis of information need and acquisition characteristics (P17-006-19). Curr Dev Nutr 2019; 3(suppl 1):nzz038.P17-006-19.
36. Johnson SL: Developmental and environmental influences on young children’s vegetable preferences and consumption. Adv Nutr 2016; 7: 220S– 231S.
