Literature review

The problem of childhood overweight and obesity is a topical and concerning issue, with over a fifth of UK children starting school either overweight or obese1. A large body of evidence has shown that accelerated weight gain in the first 2 years of life, independent of birth weight and parental weight is associated with an increased risk of overweight and obesity in childhood, and in later life2-5.

Parents and caregivers are influential in shaping their children’s behaviours, including their eating behaviours such as food preferences, consumption and even weight gain6. During infancy, children and their caregivers learn to interpret each other’s communication signals. This bidirectional behaviour forms the basis of responsive parenting, and ultimately responsive feeding. Responsive feeding is embedded in the theoretical framework of responsive parenting, which focusses on how responsive parenting behaviours can be applied to the feeding environment7.

In recent years, studies have looked at the theory of responsive feeding and aimed to determine whether the proposed link between a responsive feeding intervention and a reduced risk of overweight and obesity in later life can be substantiated, or whether there is a link between responsive feeding behaviours and increased satiety response in infants.

Breastfeeding is a naturally responsive way to feed a baby and it has been found to promote the infant’s ability to self-regulate energy intake8. The mechanisms of breastfeeding provide the perfect opportunity for baby to lead the feeding experience and nurture their innate self-regulatory ability. With breastfeeding there is no pre-planned set measure of milk and the infants take an active role in determining how much they consume in each feed. In contrast to this, infants fed using a bottle are more likely to depend on caregiver decisions. These are often made based on the visual observation of how much milk is remaining in the bottle, and infants are often encouraged to finish the bottle9. It has been suggested that the ‘feed on demand’ system that is encouraged with breastfeeding ensures that the mother and baby develop a mutual relationship and the mother is in sync with the infant’s hunger and satiety cues10.

In addition to this, research has shown that infants fed breast milk from a bottle, rather than directly from the breast were 67% less likely to respond well to their internal satiety cues. This suggests that direct breastfeeding during infancy could be associated with a better appetite regulation in later life11. Further evidence to support this comes from a longitudinal study, showing that infants fed breast milk from a bottle, compared to from the breast gained significantly more weight in the first year of life9. This evidence suggests that the slower weight gain and higher satiety response observed in infants fed directly from the breast could be contributing factors to the already established knowledge that breastfed infants are at a reduced risk of developing overweight and obesity in later life9,12.

Breastfeeding is an incomparable method of feeding infants, however when breastfeeding is not possible or chosen, infants are fed on infant formula. It is well documented that formula fed infants gain weight more quickly than their breastfed counterparts. This in turn, is related to an increased risk of overweight in later life. In addition to this, formula fed infants are thought to have a poor self-regulation of energy intake9. It has been argued that providing appropriate responses to infant hunger and fullness cues are paramount to enable the self-regulation and control of energy intake in infants to develop fully13. By adopting responsive feeding behaviours whilst feeding these infants, it has been suggested that it may be possible impact rapid infant weight gain, satiety response and overweight status of bottle fed infants.

Recent research on a responsive parenting intervention saw an effect on weight gain and overweight status at one year. It was found that infants whose parents were part of the responsive parenting intervention group had a slower, more appropriate weight gain, and when followed up at 1 year had a lower incidence of overweight than the control group. The effects of this intervention on growth and weight gain in the first year, did not differ between breastfed and formula-fed infants. Although the long-term effect of a responsive parenting intervention is not yet available, the primary results at 1 year are promising with 5.5% of the responsive parenting group of infants being overweight at one year, in comparison to 12.7% in the control group14.

In addition, research by Daniels et al. 2012 showed that infants in a responsive feeding intervention group were less likely than those in the control group to show rapid weight gain from birth to follow up15. It was concluded that an intervention aimed at educating caregivers on the ‘when, what and how’ of feeding their baby may be protective against anthropometric predictors of obesity risk, such as rapid weight gain, in the short term. Further evidence suggests that responsive feeding is likely to benefit children, with the short term benefits reflected in an increased attention to internal signals of hunger and satiety and long-term benefits proposed to include healthy nutrition and growth in later life7.

Furthermore, a systematic review by Hurley et al. 2011 found that the evidence suggests a link between nonresponsive feeding behaviours and child BMI or overweight and obesity16. Although the authors conclude that more research is required to investigate the possible causality of this association and in addition to this to test the efficacy of these responsive feeding interventions. Similarly, a systematic review by DiSantis et al. 2011b concluded that whilst there is preliminary support for responsive feeding as an influencing factor for infant and toddler weight13. It was found that the differentiation between the definitions of responsive feeding between studies, along with a failure to acknowledge the bidirectional aspects of responsive feeding could explain the observed inconsistency in findings and therefore further research is required. Considering the speculative, but supportive findings from this review, it was concluded that continued research in the form of longitudinal studies is needed, within a framework of early obesity prevention.

In conclusion, the evidence to support responsive feeding as protective against overweight and obesity is limited, but the evidence does suggest an association between responsive feeding behaviours and increased satiety responsiveness in infants. This could therefore impact future energy intake regulation and impact on overweight and obesity risk in later life. However longitudinal studies to substantiate this hypothesis are still needed.

  1. Public Health England., 2016. Child Obesity. Available: Accessed: 30th September 2016
  2. Schwartz C, Scholtens PAMJ, Lalanne A, et al. 2011. Development of healthy eating habits early in life. Review of recent evidence and selected guidelines. Appetite. 57 (3), 796-807.
  3. Boots SB, Tiggemann M, Corsini N, Mattiske J., 2015. Managing young children’s snack food intake. The role of parenting style and feeding strategies. Appetite. 92, 94-101.
  4. DiSantis KI, Hodges EA, Johnson SL, Fisher JO., 2011. The role of responsive feeding in overweight during infancy and toddlerhood: a systematic review. Int J Obes. 35, 480-492.
  5. Li R, Magadia J, Fein SB, Grummer-Strawn LM., 2012. Risk of Bottle-feeding for Rapid Weight Gain During the First Year of Life. Arch PediatrAdolesc Med. 166 (5), 431-436.
  6. Baird J, Fisher D, Lucas P, Kleijnen J, Roberts H, Law C., 2005. Being big or growing fast: systematic review of size and growth in infancy and later obesity. BMJ. Doi:10.1136/bmj.38586.411273.EO
  7. DiSantis KI, Collins BN, Fisher JO, Davey A., 2011. Do infants fed directly from the breast have improved appetite regulation and slower growth during early childhood compared with infants fed from a bottle? Int J BehavNutr Physic Activ. 8, 89.
  8. Hurley KM, Cross MB, Hughes SO., 2011. A Systematic Review of Responsive Feeding and Child Obesity in High-Income Countries. J Nutr.Doi; 10.3945/jn. 110. 130047.
  9. Daniels LA, Mallan KM, Battistrutta D, Nicholson JM, Perry R, Magarey A., 2012. Evaluation of an intervention to promote protective infant feeding practices to prevent childhood obesity: outcomes of the NOURISH RCT at 14 months of age and 6 months post the first two intervention modules. Int J Obes. 36, 1292-1298.
  10. Aboud FE, Shafique S, Akhter S., 2009. A Responsive Feeding Intervention Increases Children’s Self-Feeding and Maternal Responsiveness but Not Weight Gain. J Nutr. doi:10.3945/jn.109.104885
  11. Savage JS, Birch LL Marini M, Anzman-Frasca S, Paul IM., 2016. Effect of the INSIGHT Responsive Parenting Intervention on Rapid Infant Weight Gain and Overweight Status at Age 1 Year. A Randomized Clinical Trial. JAMA Pediatrics. 170 (8), 742-749.
  12. Harbron J, Booley S, Najaar B, Day CE., 2013. Responsive feeding: establishing healthy eating behaviour early on in life. S Afr J ClinNutr. 26 (3), S141-149.
  13. Harder T, Bergmann R, Kallischnigg G, Plagemann A., 2005. Duration of breastfeeding and risk of overweight: a meta-analysis. Am J Epidemiol.162 (5), 397-403.
  14. Black MM and Aboud FE., 2011. Responsive Feeding Is Embedded in a Theoretical Framework of Responsive Parenting. J Nutr. 141, 490-494.
  15. Stettler N, Zemel BS, Kumanyika S, Stallings VA., 2002. Infant weight gain and childhood overweight status in a multicentre, cohort study. Pediatrics. 109, 194-199.
  16. Reilly JJ, Armstrong K, Dorosty AR, Emmett PM, Ness A, Rogers I et al. 2005. Early life risk factors for obesity in childhood: cohort study. BMJ. 330, 1357.
  17. Dennison BA, Edmunds LS, Stratton HH, Pruzek RM., 2006. Rapid infant weight gain predicts childhood overweight. Obesity. 14, 491-499