Infant Nutrition: Responsive Feeding
By Diana Rice, RD, LD
Today’s Dietitian
Vol. 25 No. 3 P. 10

Recognizing hunger and satiety cues is as important as the healthful foods caregivers feed their children.

The inclusion of specific nutrition guidelines for children from birth to 24 months wasn’t the only significant addition to the pediatric section of the 2020–2025 Dietary Guidelines for Americans (DGAs). For the first time, the DGAs recognize that beyond what to feed children for optimal health, how caregivers do so also is important.

The 2020–2025 DGAs recommend a practice called “responsive feeding,” which encourages caregivers of children from birth to 24 months to become attuned to their children’s unique feeding needs, including recognizing their hunger and satiety signals and responding accordingly.

“Responsive feeding is an approach to feeding children that isn’t so much about the adult getting the child to eat in a certain way, as [it is about] the adult focusing on creating an environment that facilitates autonomous engagement with food on the child’s part,” says Jo Cormack, PhD, a United Kingdom–based psychotherapist specializing in feeding dynamics and the feeding relationship.

The responsive approach represents a significant shift in how Western culture has long envisioned feeding children. “The traditional view of child-feeding still rests on adult guidance,” Cormack continues. “We give a child a plate of food that’s nutritious, balanced, and varied, then we gently direct them to eat it. With responsive feeding, however, the emphasis is on the adult helping the child feel relaxed and secure, making meals a communal event, being attuned to the child, and respecting their autonomy.”

And beginning with this approach in infancy, rather than shifting towards it once a feeding issue occurs, is highly beneficial to children. “Virtually all humans are born with the capacity to learn to eat and to self-regulate intake,” says Katja Rowell, MD, an author and responsive feeding specialist in Washington State. “The earliest feeding experiences begin to either support internal capacities or undermine them.”

What the Research Says
Although many in the medical community agree that feeding infants in a responsive manner is beneficial, most of the research in this area has focused on the harms of using nonresponsive practices. “We know that pressuring children to eat is associated with children being more avoidant (‘picky’),” Cormack says. Nonresponsive practices also can lead to food fixations and binging, which contribute to an unhealthful relationship with food in childhood and beyond. “Directing children to stop eating (technically called restriction) increases children’s desire for the very foods that are being restricted,” she adds.

Could fostering an infant’s ability to self-regulate help prevent them from growing into larger bodies? Again, the research in this area primarily looks at the effects of doing the opposite. A 2011 systemic review found that the nonresponsive feeding practice of restricting food is associated with higher weight in childhood, while pressure to eat is associated with lower weight.1 But the association isn’t necessarily causal—raising the question of whether pressure and restriction directly influence child weight status or whether parents of children on the high and low ends of the weight spectrum are more likely to engage in nonresponsive practices in the hopes of influencing their child’s body size.

Aware of these associations, Rowell cautions clinicians not to embrace responsive feeding for its potential influence on weight status alone. “I see responsive feeding in many medical and nutrition settings stressed primarily as a way to ‘prevent obesity.’” she explains. “Some version of, ‘Let children tell you when they are done and don’t overfeed them so they don’t get fat.’ But I almost never see mentioned that trying to get children to eat more is known to lead to children eating and growing less well. While I do think responsive feeding means we are less likely to see growth dysregulation at either end of the growth chart, there will always be higher-weight children and those who are smaller than average.”

Leslie Schilling, MA, RDN, CSSD, a Las Vegas–based dietitian and author, agrees. “Body diversity has always been with us, and responsive feeding is a supportive way that can help infants grow into the body that’s genetically appropriate for them individually,” says Schilling, who’s the creator and coauthor of Born to Eat, a book about infant feeding that helps caregivers embrace the responsive feeding approach. “This means they can fall across the size spectrum and be just fine.”

Signs of Hunger and Fullness
Dietitians can help families implement a responsive approach from birth onward by helping caregivers identify an infant’s signs of hunger and fullness.

From birth to 5 months old, infants will demonstrate hunger by clenching their hands and/or bringing them to their mouths, as well as puckering or licking their lips. They’re also likely to turn their heads in the direction of an offered breast or bottle. Looking for these signs and feeding on demand rather than according to a schedule or a predetermined number of ounces during this stage helps infants feel relaxed and innately trust that enough food always will be available. Signs of fullness at this stage include infants closing their mouths, turning away from the breast or bottle, and relaxing their hands.

After 6 months of age, when infants typically are ready for solid foods, caregivers can identify they’re hungry when they get excited to see food and reach for or point to it. They likely will open their mouth eagerly when offered a spoon or see that food is available on their high chair tray. Infants signal fullness by closing their mouths when food is offered, turning their heads away, and pushing food away. Per the DGAs, these signs will continue through 23 months old, although it’s beneficial for parents to remain attuned to these cues throughout childhood.

It also may be helpful for caregivers to teach their infants hand signs for “more” (touching the fingertips of each hand together) and “all done” (waving side to side with both hands) so they can indicate hunger and fullness before they’re able to express these concepts verbally.

One popular way caregivers can begin with a responsive approach is to embrace infant self-feeding, often called baby-led weaning.

“Using a self-feeding method is truly ‘hands off,’” Schilling says. “When safe food is presented to an infant learning to eat and they have full control of what and how much they put in their mouths, that’s responsive feeding in action.”

Yet Schilling explains that feeding infants via spoon also can be done in a responsive way. “When spoon-feeding, loading the spoon and letting the child put it in their own mouths supports responsive feeding,” she says. “If this isn’t an option for the infant, having a caregiver feed using the spoon while watching for—and honoring—satiety cues can also support responsive feeding.”

As straightforward as recognizing these signs may seem, many caregivers still are motivated to ignore them out of concern for the child’s nutrient intake. “There is a striking gap between what researchers and many professionals know about the importance of responsive feeding, and the information that’s getting to parents,” Cormack says. “Often, in a bid to optimize nutrition, parents pressure and restrict because they think this supports their child’s health. Parents shouldn’t be blamed and shamed for this; they rarely have access to good quality information and advice.”

Practice Pearls
Rachel Rothman, MS, RD, CLEC, a San Diego–based pediatric dietitian and owner of Nutrition in Bloom, is a professional who recently transitioned away from a traditional feeding approach and now strives to provide quality information about responsive feeding in her clinical practice. “In contrast to many of the mainstream frameworks I learned in the past, the values of the responsive feeding approach definitely resonated with me,” she says. “The idea of really providing individualized care and listening to what a child needs instead of treating the child and their behavior as a problem to be ‘fixed’ is a big step forward.”

Rothman credits Rowell’s book Helping Your Child With Extreme Picky Eating, as well as a continuing education course on feeding neurodivergent children hosted by Naureen Hunani, RD, of the organization RDs for Neurodiversity, for inspiring her shift towards the responsive feeding model.

For dietitians interested in learning more about the approach, Rowell and Cormack co-run a multidisciplinary continuing education platform called Responsive Feeding Pro, which is dedicated to helping feeding professionals bring responsive approaches into clinical practice through webinars and small group classes.

Dietitians also can help families shift towards responsive feeding by addressing the underlying fears and worries that tend to lead them to use unresponsive practices. “The worry that the child is too big or too small, or will become so, or the worry that they eat too much or too little, is cultural and embedded in our medical system,” Rowell says.

Rothman also likes to remind the families she counsels to center their infant’s needs in feeding, as the caregivers know their child better than anyone else. “Observe your child. No matter how you choose to start solids, let your baby lead the way,” she suggests. “Respond when they open their mouths or are interested in food, and back off when they don’t. Trust that your child will meet their needs and is getting what they need. And trust yourself as a parent: Your child will learn how to eat!”

Because, after all, what babies are eating is only part of the equation. If RDs can help families with the “how” of eating as well, they can help set children up with a healthful relationship with food for life.

— Diana Rice, RD, LD, is the owner of Tiny Seed Family Nutrition, a virtual weight-inclusive nutrition counseling and coaching practice for children and adults. She’s also a certified intuitive eating counselor and the voice behind @anti.diet.kids, an online platform that helps parents reject diet culture and raise body-confident intuitive eaters. A parent to two young children herself, Rice is based in Oklahoma City, Oklahoma.

Reference
1. Hurley KM, Cross MB, Hughes SO. A systematic review of responsive feeding and child obesity in high-income countries. J Nutr. 2011;141(3):495-501.

Responsive Feeding Resources
• Responsive Feeding Pro: Learning platform offering webinars and small group classes (responsivefeedingpro.com)

• RDs for Neurodiversity: Website offering small group classes on topics such as inclusive approaches to supporting neurodivergent children with feeding challenges such as avoidant restrictive food intake disorder (rdsforneurodiversity.com)