The Journal of Nutrition

American Society for Nutrition

Responsive Feeding: Implications for Policy and Program Implementation1,2

Patrice L. Engle and Gretel H. Pelto

Additional article information

Abstract

In this article, we examine responsive feeding as a nutrition intervention, with an emphasis on the
development and incorporation of responsive feeding into policies and programs over the last 2 decades
and recommendations for increasing the effectiveness of responsive feeding interventions. A review of
policy documents from international agencies and high-income countries reveals that responsive feeding
has been incorporated into nutrition policies. Official guidelines from international agencies,
nongovernmental organizations, and professional organizations often include best practice
recommendations for responsive feeding. Four potential explanations are offered for the rapid
development of policies related to responsive feeding that have occurred despite the relatively recent
recognition that responsive feeding plays a critical role in child nutrition and growth and the paucity of
effectiveness trials to determine strategies to promote responsive feeding. Looking to the future, 3
issues related to program implementation are highlighted: 1) improving intervention specificity relative
to responsive feeding; 2) developing protocols that facilitate efficient adaptation of generic guidelines to
national contexts and local conditions; and 3) development of program support materials, including
training, monitoring, and operational evaluation.

Introduction

The previous articles in this series outlined the theoretical framework for responsive feeding (1) and
critically reviewed research on this topic in low- (2) and high-income countries (3). This paper addresses
the arena of policy and programs with a focus on 2 issues: the incorporation of responsive feeding into
policies and programs over the last 2 decades, and recommendations for increasing the effectiveness of
responsive feeding interventions.

Development and incorporation of responsive feeding into policies and programs

Perspectives from low- and middle-income countries

WHO and UNICEF, agencies responsible for child health in low- and middle-income (LAMI)5 countries, set
the standards for infant and young child feeding. During the 1990s, UNICEF recognized that children’s
nutritional status was due not only to food availability and access to health care services, but also to the
care the child received in the Care for Nutrition framework (4). WHO joined with UNICEF to define 12
family care behaviors that were necessary for child survival, one of which was active feeding. Active
feeding was initially conceptualized as an alternative to a passive, nonresponsive, feeding style that was
associated with low intake and poor growth (5). Active feeding was subsequently broadened to
responsive feeding with the recognition that controlling feeding behavior overpowered children’s signals
of hunger and satiety and often had adverse effects on children’s growth (6). Policy documents in the
past decade have focused on the responsiveness of the caregiver to the child’s signals.

The way the child is fed (active or responsive feeding) was relatively quickly incorporated into infant
feeding policies and programs. WHO and UNICEF (7, 8) produced documents emphasizing the dangers of
passive feeding, particularly in the context of high food insecurity. A Pan American Health Organization
(PAHO)/WHO publication (9) emphasized that optimal infant feeding depends not only on what is fed,
but also on how, when, where, and by whom the child is fed (5).

Responsive feeding has been recognized for its role not only in nutrient intake and growth, but also in
child development. The recommendations in the PAHO/WHO publication (9) cover 3 areas: feeding
interactions and styles, the feeding situation, and how to deal with child food refusal. The guidelines
advise caregivers to recognize children’s signals of hunger and satiety, not to force children to eat, and to
regard mealtimes as a period of learning and love. Guidelines for responsive feeding have expanded to
include the promotion of self-feeding through finger foods, attending to the child throughout the meal,
and strategies to respond to food refusal. Some examples from LAMI countries are below.

Integrated management of childhood illnesses care for development.

Responsive feeding recommendations were added to the Integrated Management of Childhood Illnesses
Card in 2000, together with a Care for Development Module, and were modified in 2009 (11). These
feeding recommendations, disaggregated by child age, include topics such as breast-feeding on demand,
being responsive to cues of hunger and satiety during complementary feeding, introducing and
encouraging use of finger foods, and increasing the infant’s exposure to food variety and tastes. The
recommendations for responsive feeding on the growth card for the WHO Growth Standards are age-
based and include adaptations from the PAHO/WHO (9) guidelines: “Do not force her to eat” and
“remove distractions,” the longest list of recommendations so far. Two new recommendations were “use
a separate plate/bowl” (1–2 y) and “give realistic portions depending on her age, size, and activity level”
(2–5 y).
Facts for life.

The most recent edition of Facts for Life includes responsive feeding recommendations not only for
complementary feeding, but also for breast-feeding and for learning and development. These
recommendations incorporate the WHO/UNICEF 2003 guidelines (8) and suggest that responsive feeding
promotes child development. It includes recommendations such as “helping the child experiment with
spoon and cup.” A gender component has been added recommending that boys and girls receive the
same amount of food and mothers and fathers both play a role in feeding. Breast-feeding
recommendations emphasize bonding and a close, loving relationship to promote “learning, love and
interaction, which promote physical, social and emotional growth and development.”

In addition to WHO and UNICEF, responsive feeding recommendations are being implemented by many
other agencies working in LAMI countries. For example, the nutrition counseling card used by CARE
includes recommendations primarily designed to address problems of passive feeding and
undernutrition. The card includes messages about feeding with patience, encouragement to eat, and
monitoring/supervision during feeding.

Perspectives from high-income countries

Responsive feeding has been incorporated into research and practice in high-income countries,
particularly among children experiencing poor growth. Research on failure to thrive and an increasing
interest in early child feeding among pediatric psychologists have led to new areas of research and
practice. Black et al. (13) demonstrated that children’s food intake increased with improved care, and
Satter (14) operationalized the principles of responsive feeding through the “division of responsibility,”
whereby parents are responsible for providing healthy food on a predictable schedule in a
developmentally appropriate setting and children are responsible for the amount they eat.

Examples of programs and policies related to responsive feeding in high-income countries are discussed:

The Start Healthy Feeding Guidelines for infants and toddlers.

The American Dietetic Association Guidelines (15), which appeared in 2004, mirrored many of the trends
seen in the global literature, incorporating a comprehensive approach to responsive feeding. The
Guidelines emphasize feeding responsiveness and the link between responsive care for nutrition and
development. They incorporate Satter’s (14) work on the division of responsibility between the parent
and the child. Other recommendations include recognizing the child’s developmental ability, balancing
the child’s need for assistance with encouragement of self-feeding, and responding appropriately to
hunger and satiety cues.

USDA Center for Nutrition Policy and Promotion.

The Public Information for Families on Child Feeding published by the USDA (16) includes a Tip Sheet in
which 2 of the 10 tips relate to responsive feeding by emphasizing the importance of a happy, fun meal
environment, the need for a positive role model, and the dangers of force feeding and lecturing during
meals.

Infant and Toddler Forum.

In response to the recognition that good eating habits early in life have long-term health benefits, the
United Kingdom has initiated disease prevention, health promotion, and early nutrition intervention
through programs such as the Infant and Toddler Forum (17), which includes representatives from
pediatrics, dietetics, and child psychology. The forum evaluates scientific evidence and translates it into
messages for parents, health, and child care professionals that integrate nutritional science with social
and practical issues necessary for optimal diet and feeding practices. Their recommendations and
education materials include guidelines about a positive eating environment, responsivity to children’s
cues of hunger and satiety, feeding schedules and routine, and developmentally appropriate strategies to
deal with food refusal.

There are many similarities between the high-income and LAMI countries in the messages provided.
Both emphasize the importance of responding appropriately to cues of hunger and satiety, being a
positive role model, and addressing issues related to food refusal. Two notable differences in the high-
income countries are the much greater emphasis on the child’s developmental skills and the child’s
autonomy and decision-making about how much to eat. One possible reason for the difference is that
high-income countries are concerned about overnutrition and child development, whereas in LAMI
countries, the overriding concern has been about undernutrition and poor growth.

Why has responsive feeding entered policy instruments so rapidly?

Over the past decade, responsive feeding has been incorporated into policies in both high-income and
LAMI countries. Research in developmental psychology has clearly shown that increasing responsive
interactions results in improved cognitive and language development (18), but research linking
responsive feeding to growth is limited. Despite the relatively recent recognition that responsive feeding
plays a critical role in child nutrition and the lack of effectiveness trials demonstrating that increases in
responsive feeding affect growth, there has been a rapid development in the policy arena. We offer
some suggestions for this phenomenon.

Despite major economic, social, and nutrition interventions, progress toward the millennium
development goal to reduce undernutrition has been slower than projected. Although many factors are
outside the purview of the nutrition community, the situation has motivated nutrition policy
professionals and advocates to identify new intervention pathways. Expanding the focus from foods to
feeding behaviors is a natural outgrowth of this motivation. The advancement of a theoretical basis for
responsive feeding (1) has provided the scientific rationale for investing in responsive feeding.

Research on causes of childhood obesity, an emerging problem in all countries, suggests that both
controlling and indulgent feeding may be contributing factors (3). Nonresponsive feeding behaviors, in
which parents over- or underregulate feeding without responding to child signals or dietary
requirements, have been associated with poor self-regulation of feeding and increased weight gain and
overweight/obesity. Responsive feeding offers an important avenue for interventions to prevent
childhood obesity, and part of the explanation for the rapid incorporation of responsive feeding into
nutrition interventions may be due to expectations about responsive feeding as a strategy for controlling
the obesity epidemic.

Feeding problems are major concerns for health workers and child caregivers. Studies in LAMI and high-
income countries show between 20 and 40% of parents are concerned about children’s food refusal,
intermittent eating, or other feeding problems (19–21). Parents are often more sensitive to problems in
their child’s mealtime behavior than in their growth (22).

Finally, responsive feeding messages are attractive because they are positive and effective. Caregivers
can see the results of trying out suggestions and the feedback loop is short. The new behaviors often
help the mother as well as the child. A child who does not eat is a logistic and emotional challenge to any
caregiver. Greater success with feeding, as well as recognizing that feeding problems are common, may
alleviate the caregiver’s negative experiences and increase her confidence. She may also think that she is
helping her child’s development.

Increasing the effectiveness of responsive feeding interventions: next steps

A recurrent theme is the need for careful, well-designed research to establish a strong knowledge base
on program efficacy and effectiveness. Research is needed not only for intervention content but also for
implementation strategies. Three research topics of particular urgency are: improving the specificity of
responsive feeding interventions for different types of feeding problems, a systematic method to adapt
generic guidelines on responsive feeding to national contexts and local cultural conditions, and
programmatic research to develop better tools for training, program monitoring, and operational
evaluation.

Improving the specificity of responsive feeding interventions

The central recommendations for responsive feeding are proactive preparation, such as ensuring the
availability of healthy food and a safe and comfortable environment for the child, and the caregiver’s
sensitivity and response to the child’s signals (1). However, there is less information to guide decisions
for specific types of feeding problems. For example, recommendations to passive feeding caregivers may
include increased supervision and assistance to the child, whereas recommendations to controlling
feeding caregivers may be to allow the child more autonomy and improve strategies for recognizing the
child’s signals and providing encouragement. Other factors such as the child’s appetite will affect the
intervention strategy. Research that leads to greater specificity in program design in relation to types of
feeding problems will improve the efficiency and effectiveness of interventions.

Adaptation of guidelines/recommendations for program development and implementation

It is expected that responsive feeding recommendations, presented in the form of generic program
guidelines, will continue to evolve as research on responsive feeding yields more precise evidence about
the mechanisms through which the processes affect child growth and development. At the same time,
the experiences in implementing responsive feeding programs in both high- and low-income countries
document the importance of adapting programs and recommendations to national contexts and local
conditions. For example, in Peru, formative research resulted in the recommendation to “feed your child
with love, patience and good humor” (23) and in India, where there is little self-feeding, it led to a
recommendation to “let the child try to eat by himself if he shows interest” (24). A major challenge for
translating policy into effective programs is efficient and effective adaptation.

At the level of strategy development, assessing organizational options facilitates the planning process.
For example, because responsive feeding is closely allied to other child development issues, nutrition
and child development activities may be programmatically linked. In Europe, responsive feeding
messages have been introduced into parent education interventions and focus on issues such as
behavioral management strategies, parent-child interaction around food, encouragement of self-feeding,
limiting force-feeding, and cognitive-behavioral strategies for food phobias (25, 26). LAMI countries such
as Kazakhstan and Georgia incorporated responsive feeding into their parenting programs (27).
At the program level, formative research to adapt guidelines to local cultural contexts typically faces
serious resource constraints, yet without adaptation programs may fall short of their potential. One
approach to local adaptation of generic guidelines is the method that was developed by the Acute
Respiratory Control Program at WHO (28, 29). To meet the need for an efficient method of translating
policy guidelines into local programs, the program developed a successful tool for conducting local
adaptation studies. Investing in formative research tools is a priority for furthering effective responsive
feeding program implementation.

Monitoring and operational evaluation

The challenge of translating research into full-scale sustainable implementation is a major concern in
nutrition and public health. Often retrospective evaluations, both formal and informal, find that impact
has been diluted or even abrogated, because critical features in the intervention delivery pathway have
not functioned well. The nutrition evaluation literature contains many examples that illustrate the types
of problems that prevent interventions from operating as originally conceived (30).

Although there are generic management tools that a responsive feeding component could draw on, they
also require local adaptation to identify the context-specific issues, not only for the initial, start-up
period, but throughout the life of a program. As with all types of nutrition and health interventions,
some aspects will be subject specific and require subject-specific guidelines. Subject-specific challenges
for responsive feeding need to be identified and utilized in program management.

The concept of program impact pathways analysis (PIP) has been proposed as an approach for planning
and monitoring interventions (31). Whereas the basic template for creating an initial PIP draws from
scientific literature in the relevant (biological and social science) fields of the intervention, a PIP must be
context specific and the program managers must have a mechanism for obtaining feedback as the
project proceeds. Monitoring what is occurring along the pathway from the introduction of the
intervention to its biological impact provides the means for identifying bottlenecks or nodes that need
attention. The development of an empirically based, generic PIP for responsive feeding, together with
guidelines for adapting it to local contexts, would be possible with the current level of knowledge. Using
the PIP approach would help to determine whether an intervention was able to increase responsive
feeding and whether it affected growth. Monitoring responsive feeding requires a consistent definition
and common indicators. Although behaviors could be observed, indicators that caregivers can report are
easier to collect. In urban Peru, caregivers were able to recall and accurately report certain behaviors
such as the relative amount of child self-feeding (32). Similar research is needed in other contexts.
In conclusion, responsive feeding has been incorporated into infant and young child nutrition policies by
many organizations in both high-income and LAMI countries. Recommendations vary by organization and
have expanded to include more aspects over time (e.g. gender) but have retained core elements of
feeding, such as caregiver responsiveness to the child’s cues of hunger and satiety. Although responsive
feeding in combination with other interventions improves growth, the empirical evidence that
responsive feeding interventions alone will reduce overnutrition or undernutrition is suggestive but
limited (1–3). Despite the absence of effectiveness trials, the rapid incorporation into policies may reflect
the ubiquity of child feeding problems, the need to address the dramatic increase in child obesity, and
the appeal of promoting positive message through responsive feeding recommendations. Additional
research is needed, not only to develop and evaluate the effectiveness of strategies to increase growth
through responsive feeding, but also to adapt messages for varied cultural contexts, as well as to
monitor their impact.

Acknowledgments

P.L.E. and G.H.P. were involved in the design, analysis and review, and writing of this manuscript. Both
authors read and approved the final manuscript.

Footnotes

5Abbreviations used: LAMI, low- and middle-income countries; PAHO, Pan American Health
Organization; PIP, program impact pathways analysis.

Article information

J Nutr. 2011 Mar; 141(3): 508–511.

Published online 2011 Jan 26. doi: 10.3945/jn.110.130039

PMCID: PMC3040908

PMID: 21270361

Patrice L. Engle3,* and Gretel H. Pelto4

3Department of Psychology and Human Development, California Polytechnic State University, San Luis
Obispo, CA 93402

4Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853

1Published as a supplement to The Journal of Nutrition. Presented as part of the symposium entitled
“Responsive Feeding: Promoting Healthy Growth and Development for Infants and Toddlers” given at the
Experimental Biology 2010 meeting, April 25, 2010, in Anaheim, CA. The symposium was sponsored by
the International Nutrition Council. The symposium was chaired by Kristen Hurley and cochaired by
Maureen Black. Guest Editor for this symposium publication was Laura Murray-Kolb. Guest Editor
disclosure: Laura Murray-Kolb had no relationships to disclose.

2 Author disclosures: P. L. Engle and G. H. Pelto, no conflicts of interest.

*To whom correspondence should be addressed. E-mail: ude.yloplac@elgnep.

Copyright © 2011 American Society for Nutrition

This article has been cited by other articles in PMC.

Articles from The Journal of Nutrition are provided here courtesy of American Society for Nutrition

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