Alimentación perceptiva: Desarrollo de hábitos alimenticios saludables desde el nacimiento

(En inglés)

Responsive Feeding: Developing Healthy Eating Habits from Birth

April Powell: Welcome, everyone, and thank you so much for standing by with us. My name is April Powell, and I'm the resource program manager for the National Center on Early Childhood Health and Wellness, and I'm so pleased to welcome you all to today's webinar on responsive feeding. Before we begin the presentation, I have just a couple of webinar announcements. First, all participants will be muted throughout the entire presentation portion of the webinar. There is a slide presentation being shown through the webinar system that only the presenters will be able to control. If you have a technical question, please type it in the Q&A box of the webinar. There's a lot that will be covered within the next hour, but you can submit your questions at any time just by putting it in the chat box. Only the webinar staff will be able to see your question. Some questions we'll be able to answer right away, and other questions we'll answer at the end during the Q&A period. If for some reason we don't have time to get to your question, we'll have a conversation via My Peers about responsive feeding and we can answer your question there. There will be a video played during the webinar presentation. 

Only the sound-- excuse me, the sound will only be played through your computer speakers. So you've called in through the phone, you won't be able to hear the video through your phone. You'll have to listen via your computer speakers. Immediately following the webinar, you will be prompted to take an evaluation. At the end of the evaluation, there will be a link for you to fill in your name on a certificate and print it. If for some reason you can't get the link to work, there will be a post-webinar email that also has the certificate in it. So you'll have two opportunities to print off your certificate. This webinar is being recorded, and an archive version along with the slides will be available to you in that post-webinar email that I was telling you about. So, today we have two expert speakers, Jodie Fishman and Florence Rivera. I'll let them introduce themselves, and now I'm going to turn it over to Florence. 

Florence Rivera: Thank you, April. So, as she said, my name is Florence Rivera with the National Center on Early Childhood Health and Development. A little bit about myself. I have my bachelor's in dietetics, my master's in public health, and started my career managing WIC clinics, Women Infant Children clinics, and then developed their Early Head Start program in homeless shelters throughout Chicago, where I also worked as a health educator before working for the National Center. And so I hope to bring a little bit of that experience to our discussion today about how we support families in responsive feeding through home visits. 

But in addition, I'd like to share just a little bit of my personal anecdotes, as I have a 3-year-old and a 5month-old, and have really felt like that was probably the best education about how to do responsive feeding, and maybe how not to do it. So let me get started, and then I'll turn it over to Jodie when we're finished. Now, as April said, we'll try to answer your questions, if you want to put them in the chat box. If we don't answer them today, we'll make sure to follow up and get you all the answers that you need. So our objectives today. We hope to give you some information on responsive feeding, what is it, why is it important, and how this can be beneficial for families. We also hope to give you some strategies of how to help families think about how they can incorporate this in their own lives and recognize throughout the presentation that this is going to look different for every family. And we'll introduce hopefully this new suite of materials, which includes this side set. You'll have-- actually, there are three modules and they all are populated with speaker notes. But there will be more slides in the actual modules than what we're presenting today, but it gives you a taste of what will be available. 

So an agenda. We're going to provide everything you ever wanted to know about responsive feeding. And I'll probably add some things you didn't. And then, of course, answer your questions and show the new suite of materials. What is responsive feeding? It's actually a dimension of responsive parenting, and it's this give and take method for how we feed our children. And we really boil it down, without reading this whole definition, to parent provides, child decides. And I wanted to leave that statement here for a minute, because this is really very different to how a lot of us, a lot of our families end up parenting our children. We tend to be very directive. You know, you think of comments such as, hurry up and put on your shoes. We have to go there. Don't put that in your sisters nose. Those are all very directive comments, and responsive feeding is an effort to really let the child lead meal time. And so it's a very different feel of meal time than, perhaps, what some of our families are doing currently, and really some of ourselves. And I'll talk about this later, a lot of us are raised in a clean your plate mentality, where we are looking for external cues of hunger and fullness. And we're not really primed to set up an eating environment that has a give and take and control to the child. 

So we'll think a little bit through that today, as well. Okay, so benefits of responsive feeding. Why is helpful to children and families? First off, it supports their self-regulation. All babies are born with this ability to understand when they're hungry or when they're full. We understand when they're hungry or when they're full because they're crying, right? And then we'll see some of the satiety or fullness cues here in a little bit. But what happens is we start losing that ability to self-regulate, we stop listening to those internal cues of when our body is telling us when we are hungry and when we are full, and we start looking for external cues. And a reason why we do this is because the feeding environment, or the non-responsive feeding practices when we're young, that we teach children that they should be looking to us for signs that the meal time is over. And so responsive feeding, excuse me, really supports the skill set that we're all born with. 

So that we can take that as we get older and all the way into adulthood, that we're really listening to our bodies. And if you think about a time that you have ever eaten when you weren't hungry anymore or, you know, finished the bag of potato chips just because there were still some, those are all external cues -- or cleaned our plate because there was still food on it -- external cues of whether or not we are full are hungry. And responsive feeding also builds attachment. So and I'll talk about this in a couple -- I think it's the next slide where we have a nice graphic. So I should just go ahead and move onto that. We're setting up this cycle, essentially -- the child communicates in whatever form they have the capacity to communicate that they are hungry, and that the parent or caregiver responds in a very emotionally supportive and developmentally appropriate way that tells the child, I hear you. I understand you, and I'm taking care of your needs, and that helps build attachment, that the child understands that the way that they have communicated is sufficient and that the parent understands them and is going to care for them.  And then the child experiences the predictable and consistent response. When I have this cry or I say these words, I'm going to be sad, cetera. So my next couple of slides are about the basics of infant feeding, and then we get into toddlers and preschoolers. But I think this is information that's really helpful for all families, but all home visitors to know. A lot of what we present today will be about how do you work with families to make this work within their environment, within their routine, and you have to be very comfortable with infant and child feeding to be able to do that. That hopefully, you're not just giving this information, that you're finding more about them and what works with them. And so hopefully, staff can become very comfortable with these next few slides. So infant feeding. The basics -- should be fed only breast milk or formula for that first year, excuse me. And I really want to emphasize that that is the foundation of nutrition. That a lot of families tend to think that, when we introduce complementary foods, so our baby foods, about six months that we're now transitioning to our nutritional foundation being those complementary food. And that's not really true in that first year. We're really getting our nutrition needs from breast milk or formula, and this period of six months or so is a transition period where we can become more prepared to be weaned from the bottle or the breast. Hopefully, we're holding our child while being fed. And again, that goes back to that responsive factor. And we're not propping the bottle. And it's building the attachment. And we're not propping the bottle, which goes to that responsive factor.

I cannot read your signals of fullness if I'm not there to watch them. 

And so if I'm propping the bottle, or letting them walk around with it as they get older and not holding them while they're being fed, then I'm not practicing responsive feeding because I'm not there to listen to what they're trying to tell me. And infants, we're feeding on demand. And no water for the first four months. I find a lot of families have a lot of misconceptions or family traditions and myths around giving water or even juice in those first few months due to constipation issues. And I encourage you -- hold on, Claire, I'm going to answer your question in just a second -- so I encourage you to think about that with can we find other reasons why the constipation. Typically, if it's a formula-fed baby, you might be overfeeding. Or you might need a formula change, and so forth. So try to work through some of those things other than saying no water or no juice. Recognize that they're often doing that in response to a concern. And I just want to -- Claire's asked, what if a baby can hold their own bottle? Can we sit with them in a chair? Absolutely. You know, a nine-month-old may not want to be held as depicted here in this picture when they can hold their own bottle, absolutely not. But it's still an opportunity to bond with them. And you're probably introducing other things, such as the cup at this point. And at nine months or so, they have the development of the pincer grasp, so they're probably a lot more advanced in terms of the food that you're serving them. 

But there are still ways to interact with them during meal time and not walk away from the meal time, which I think we talk a little bit more about toddler and preschooler. So hopefully, that answers your question, Claire. And no cow's milk should be given to the infant. So in that first year of life, we really want breast milk or formula, and I think a lot of families feel that cow's milk is similar or the same to formula, and so they don't understand that difference. And it's very helpful to be mindful of that, that formula is giving a much wider variety of nutrition than cow's milk is ever able to provide. There we go. So these next few slides, I'm not going to read to you, but it's really helpful to be comfortable with them yourself, and to also help families articulate some of these things. You know, if I'm asking a question to families, I always say, how does your baby tell you when they're hungry? And they very often can tell you exactly what they're doing, these bullet points and as they get older, parents start recognizing particular cries for hungry versus wet versus I just want to be held, to the point where they can mimic them themselves, which is kind of entertaining for a home visitor, but it also tells me that they're listening to their baby, that they're looking for these things and they understand what their baby is communicating with them. But I specifically ask a separate question -- how do you tell me that -- how does your baby tell you that you're full? And very often, I'll get these bullet points, but sometimes they don't. 

Sometimes they can't articulate this, and that tells me a couple of things. It tells me that they may not understand what these signs are that their baby is giving them or that they might be overfeeding them, they're looking at a number of ounces versus understanding when their baby has had enough at that time. And you'll see that a lot with the, you know, not wanting to waste formula, if they're formula fed babies, and trying to encourage them to eat those last couple of ounces so they don't have to throw it away. And so I'd like to separate those in separate questions so that I can understand that the parents are listening on both sides. And, again, I won't read the bullet points to you, but just know that as communication strategies in infancy progress, they become more sophisticated as we get older, and to the point where we actually start communicating in later infancy, which we'll talk about here in a second. But I want to move on to complementary foods, you know, introducing solid foods to babies. Our general recommendation is around six months we want to -- that's usually the time that children are experiencing these milestones. 

But why I really like to talk about it in the context of milestones to families is that it encourages them to listen to what their individual baby is telling them, and recognize that, at five months, their child may not be ready. And I, you know, I seen it on the other side, at seven months. They may be ready for whatever reason. But I'm looking for these particular skills. I'm looking whether or not their child has good head and neck control, if they can sit with some support. On the tongue thrusting reflex is fading, I don't say is their tongue thrusting reflex fading. I say, when you give them food from the spoon, do they spit it right back out? Or are they able to move it to the back of their mouth? And that's a huge milestone that I'm looking for. And also the sucking reflex, coordinated swallowing. So they actually are able to swallow it or do they choke on it? Those sorts of things that I'm looking for. And that helps encourage families to really listen to what their baby is telling them. Oh here's an interesting question from Beverly. What about the infant that is a poor cue giver, sleeps a lot, and therefore, ends up as a failure to thrive infant? So, I hear that question a lot. And there are several reasons that maybe behind an infant being poor cue giver that don't necessarily lead up to failure to thrive. But that's a medical issue that we really need to bring the medical home in for that. We would not diagnose a child who's not giving any hunger or satiety cues. 

And we wouldn't force feed them. We would need to refer them to the medical home to find out why. So I hope that answers your question. I see another question here, from Hilda, about what if the doctor places the baby on cow's milk. I've seen this a couple of times, especially in late infancy, when you have a child who has put on excess amounts of weight. And we're worried about setting this pattern for obesity as the child ages. And so the doctor has written a prescription. And that's something I wouldn't argue with in later years. But I do like to make sure that their medical home, and is a constant source of care that they're following out with the physician, and that they're also, you know, in later infancy, also having a diverse offering of solid foods. So I'll just add that in there. Okay. And so these are the signs of hunger and fullness in middle infancy. So we get a little more sophisticated and we are communicating a little bit more. All the way into my favorite period, the nine to 12 months, and they are able to throw food, and rub food in their hair or the dog's hair, which are wonderful signs of fullness that my own children have shown me. But this is a great opportunity. Also I've seen a lot of really care providers teach sign language and communication strategies, which is a wonderful way to support literacy, but also a less frustrating way for you to determine whether or not your child is hungry or full. These are some questions that we designed, hopefully, to help you work with families to think about some of this. 

Again, identifying their own baby's hunger satiety cues. How does your baby tell you when they're hungry? How do you how does your baby tell you when they're full? Create a calm feeding atmosphere that encourages bonding with their baby. And this is just a sample of what you could say. Now I will say, working at homeless shelters with families, and, you know, I've spoken with other home visitors. And they thought the same way, that sometimes you feel a little silly saying create a calm feeding atmosphere, when your life is chaos. But I encourage you to help families think about what that might be for them. Because if you think about the context of the rest of their day, the meal time might be the only time that they can create some semblance of a calm feeding atmosphere. It might also be the only time that they have the luxury of interacting with their child, in a very relaxing give and take kind of style. I mean, my own perspective, I get up very early. I commute forever and I work all day. 

And I commute back. And I pick the kids up. And I make dinner. And I entertain them when I'm making dinner. And we sit down and finally that is throughout my entire day, 12 hours, 13 hours after waking up, for the first time, I'm sitting down with them. It's the first time I'm having a calm moment, that we've turned off music, and phones, and emails, and everything else. 

So even if you feel like this family just really can't do this, this is not in their wheelhouse, it might be a perfect opportunity to start creating some of those routines with their family. And so it also helps families recognize when their baby's ready for solids. How you know when your baby is ready to start solids? And I really like this open ended question, because I'm not giving them information about how your baby's ready. But I'm starting a dialogue about how you might recognize it, at some point. And that's why it's important that home visitors are very comfortable the content I just presented. Because your opportunity might be just very short. It might be kind of spontaneous. And so you have to be comfortable, kind of, providing some other content when families are ready for it. So now we're talking a little bit about toddlers and preschoolers. And I was just checking the chat box. I don't see any questions but I'll make sure to go back in case we can answer any. But so as we get a little bit older, we're getting more into routines, right. We're getting less I demand, necessarily. And we're setting up regularly scheduled times for meals and snacks. 

So families can still do this. And hopefully, they've set up very clear expectations in infancy that in toddlerhood in preschooler age, that we're transitioning very well into this positive eating environment. So that they're sitting down making eye to eye contact, that they're turning off all those distractors, like phones, and TV, and et cetera. That they're setting clear expectations and establish routines. Now this actually might seem very burdensome for a family, but could be their best weapon against picky eaters or chaotic meal times. If you're really establishing how much time you're going to have to eat, what your options are during eating, what sort of rules and expectations that we have, the toddler and preschooler thrives off of these. And they learn exactly how you want them to behave and establish those long term patterns by doing that early. So if you have the child who, again, at this age is, perhaps, throwing food, or getting up and leaving the table, or thinking that mealtime is really this five-hour buffet where they can come back and ask for more or different options, look at meal time routines, the eating environment, and how expectations can be established to let toddlers and preschoolers know before they ever ask what is allowed and what isn't. What is appropriate and what isn't. So encourage your child to listen to their own fullness and hunger cues. In a couple of slides, I have some examples of things that you can say and what this looks like. Because I think a lot of us say, okay, I'll do that, but the way that we end up saying still tends to be very directive. 

And so I'll give you some examples here in a little bit. Engage the child in a positive give and take conversation style. Jodie is going to present one of my favorite questions later in the hour, and it's how do you make your baby laugh during meals or how do you make your child laugh during meals. And I love that question as a parent because it makes me think, one, of the 45 minutes of calm that I create through an entire day to interact with my child, and it reminds me of memories of how I'm able to create a conversation and learn about her day or tell her stories about mine and giggle with her and all of those things. Very empowering for me as a parent to recognize that I've done something very positive in our day when it feels like all I've done is maintain the status quo.  So what if the child -- and I think this is important to think about with families, as well. 

So I said parent provides, child decides. What if my child's deciding? What sort of decisions am I giving them? And one is whether or not they're going to eat. They may have to come to the table, but they can choose whether or not they're going to eat. I'm not going to force them to eat. Also, they're going to be able to choose what food they're going to eat from those being offered. Now, that's not saying that I put 16 different options on the table. It's saying that I'm serving a lean protein -- let's say a very simple baked chicken and a vegetable and maybe some fruit and a dairy to drink -- and they can choose from those what they're going to eat. I don't offer alternatives. There's no substitute at the end. Which I think can feel very frustrating sometimes because of the interaction that that might generate in terms of, let's say, a temper tantrum or a child pushing back on you. But it also gives me as a parent the permission to say no. It's going to be okay. These are healthy foods. These are your options. And to create those own boundaries around meal time, I find a lot of parents and -- without calling out my mother-in-law directly -- you know, grandparents, they struggle a little bit with putting boundaries on what a child can and cannot -- what their choices are mealtime. And they can also decide how much they're going to eat. They might try one bite. 

They might try 16. They might want seconds. It all depends on the day and their mood. If you've ever been with a toddler or preschooler for more than five minutes, you notice it's kind of par for the course. They can also request smaller portions or decline a particular food item. Even if they ate that from yesterday or last week, toddlers and preschoolers are notorious for going on food drives, so they only want to eat the same food. Or declining food that they had eaten previously that used to be their favorite. And they can decide later in the meal to try food they declined earlier, which is hopefully where the parent comes in. It's encouraging, that consideration. So Carla has asked a question about CACFP requiring that you put all foods on their plate, so how can they just decline foods they don't like it? Well, I think you're asking a very programmatic question when we're talking to home visitors, so I'm going to answer it as both. 

So as a home visitor, we're talking about what they can do at home. But at home, I would still have the same recommendations as I would for a program setting, that I'm still asking them to put all of the food on their plate. that I'm not making them eat it. That we all have it on their plate, even if a very small portion -- it's only as a spoonful -- but I'm not saying everyone has to have a bite. For a programmatic answer, other programs do participate in the thank you bites or the two bite club and so forth, and that's their strategy, but CACFP does not require that they actually eat all of the foods that you offer them. It's simply that they didn't serve them. So hopefully that answers your question, Carla. Oh. Here's a good one from Kelly. Okay. How do you handle a toddler and child who says they are done but then wants more to eat later? How do you help them know the difference between fullness and not just wanting to eat what is provided? That's a long process. And I have here on a slide about being patient. And I feel like you should just put this on the top. It should just be better for all of your slides. Because you have to be patient. This is a learning process for the parent and the child. So how do I handle a toddler who says they're done, but they want to eat more later? I offer the same food that was offered at dinner. There's not snack option. It's not you don't eat the baked chicken, and vegetable, and fruit that I offered, and then an hour later come to me and ask for pretzels, or goldfish, or something. That's not how this works. You're going to go back and be offered the same healthy food, because that's their role as a parent. I'm offering the food. I'm in control of what foods are offered. 

And then how do you help them know the difference between fullness and just not wanting to eat what is provided? And again, that's a learning process for the child. And my role as a caregiver is to give them opportunities where they're evaluating their internal cues. And that's a fancy way of saying asking them, how does your tummy feel? Are you full? Do you want more? And helping them determine that. And they're not going to get it right every time. And you're going to have to go back when they say they're hungry again, offering those same healthy foods that we offered. So hopefully that answers your question. It's a very frustrating process, as is most things with toddlers and preschoolers, I'll have to confess. But it's a very long learning process, and it takes a lot of patience of caregivers and parents. So let me see. Let me get back on track here. So with parents, hopefully they're offering these healthy foods. They're building the mealtime routines that work for them. 

So not every family is going to be able to offer a meal time where they're eating as a family every single night. It might be once a week. It might be breakfast on Tuesdays. It might Sunday night. It just depends on what works for them. And so the power of a home visitor is to really help families think through some of that. What are your routines? What are some things that you do together? And then again, interjecting small strategies or changes that they can make to enhance what they're doing. And role model the habits they want their children to build. Most parents will be able to answer the question of what sort of healthy habits do you want for your child? Or how do you want your child to eat when they're older? Do you want them to eat all the food groups? Do you want them to be healthy eaters? That sort of thing. Most parents want those things. I've never run into a parent who was like, no. I really want to live off potato chips and soda for the rest of their life. Helping parents get to, well, how do I build those habits is the hard part. And a part of that is role modeling these habits. 

So if you want your child to eat from all the food groups, do you serve them all the food groups? Do you try all the food groups? And helping families think through some of that for themselves. So recognize and encourage their children to listen their own hunger and fullness cues, which again, on my next slide there's some thoughts about how they could do that. Share cultural tradition. You know, I recently just had a conversation with my 3-year-old around why her lunchbox is often filled with different foods than the other children. And part of that is cultural, that she comes from a different culture than some of the other kids there. And part of that is because her mommy's a dietitian, and there are only going to be certain options in her lunchbox. But having that conversation during meal time, I get to share a little bit about who we are, where we come from, what sort of cultural values and food that are important to us. And that's a great time during meal time, and it explains some of the foods that we're having for dinner, and so forth. And involve their children in preparation or even cooking. 

Now, I think we say this a lot, but I'd like to tweak this for families' sake. This is actually a strategy for you. This is a tool for your picky eater, that if they feel more involved in the meal time environment, they're more willing to try new foods, they're more willing to eat the foods that you are offering, and they're going to exhibit better meal time behavior, that they're going to understand what the expectations are, and they feel more involved in the food prep. And so I really try to talk about that with families as a way to engage their child in a strategy for picky eating. And also, not just in the preparation or cooking, but in the buying the food. If you go to the grocery store with them, have them pick out a particular food to try. Have them find what it is you're looking for your list and so forth. Supporting child fullness cues. So this is the slide I'm talking about. Research tells us that families and also early care and educators often use these phrases. We often say, eat more of that. 

Can you please try one more bite? And you have to eat your spinach before you can have dessert. Those are actual words that we've been quoted as saying in the program setting and at home. That tends to be our more common kind of go statements. And what do you think is wrong with those? Why are those not sufficient? Just think about it. And if you're brave enough to put something in the chat box, feel free. But I'll tell you the answer-- that they are very directive. We are telling that child, don't look at your internal cues. Don't listen to your body. I'm telling you that you're not done. I'm telling you you need to have one more bite. And I'm also telling you that spinach is something that that needs to happen before something really good, like dessert. So I'm already creating this hierarchy of vegetables to ice cream. They seem very forceful. They do. Instead, try are you full? Have you had enough to eat? My favorite -- what does your tummy feel like? Because that asks the child to stop and evaluate whether or not their body is telling them something in particular. What would you do when a child is so picky that they would not eat anything? And it's not that he doesn't like it, it's that he doesn't want to eat. So I've come across this quite often. And what I will tell you most of the time is once I do a nutrition assessment with a family, I find out that they're often consuming too many sugar sweetened beverages, that they often walk around -- or milk. That they often walk around with some sort of sippy cup full of juice, Gatorades, milks, sodas, et cetera, and that when I'm able to cut that out, the child comes right back to the table. 

Now, I'm speaking for typically developing healthy children. Of course, there are those with medical conditions that this would be a whole other webinar about. But if I'm talking about a typically developmental child, healthy child, they're going to come to the table when they're hungry. Often, when they're not feeling hungry, that they want to play more often than not, they're consuming other calories. Because in a healthy child, they do experience hunger and they'll be motivated to eat. And what I find is often when I'm working with families and they're able to switch out some of those beverages for water, that the child comes right back to the table. Okay. And I have a couple of more slides before I turn it over to Jodie. So the "clean your plate" mentality. Many of us grew up this way. I know I did, as well. You had to clean your plate before you're considered done, and that's a very strong external cue of whether or not I've had enough to eat. And so it's often indicative of how we have lost our ability to self-regulate in terms of listening to our body's cues of hunger and satiety, where we tend to eat long after we're full. And then I will also add that these are great questions to pose to other staff and to families. But be very careful that you're going to probably get some responses tied to food insecurity, which I'll let Jodie talk about in a little bit. 

But just be prepared for those conversations. Not that you shouldn't ask these questions, but you should know that that will come up. Using food as a reward or punishment. A lot of times, you'll find this, and I find myself saying this, too. If you take a bite of that vegetable, we'll let you have dessert. Or if you don't pick up your toys, you can't have some snack pack that you want. The reason that we do it, one, is because it's an easily controlled environment. Like that's something that we can go to his parents as some form of leverage. I mean, very often when you're negotiating with toddlers, it feels like you're negotiating with terrorists and that they're holding you ransom for some sanity. And so you're really trying to pick at anything you can to negotiate some end result that you're looking for. And so try to work with families. And not that this is -- and I wouldn't approach it as a way that you're doing this wrong, but help them recognize that when you tell them this, that you're telling them that a vegetable is not as good as a dessert, and that when you're withholding food before they do something, it's just not the best strategy. And so try to help them think of some other things. I have some examples that you could use here. 

Yeah. So Connie had -- and Jodie is probably going to kill me because I'm taking a lot of time. But I will say Connie has a really great comment here. It says that it always amazes me that we can listen to the fullness cues of an infant who can't speak, but when a toddler says the words I'm full, we ignore them and try to trick them into taking two more bites. And I absolutely agree. Now, I will say, we also tend to do it for infants, as well. We try to listen, but we have a lot of anxiety. We, being families, have a lot of anxiety about our young children eating enough. And a lot of that is tied back to what food represents for us. It often represents if our baby is gaining enough weight, whether or not they're healthy, whether or not we're getting the hang of this parenting thing, if we're feeding our child enough, and whether or not we're showing them enough love. Does that really mean a lot more to them than whether or not they're child is being nourished? 

So when you're talking with families about responsive feeding, recognize that they're going to have a lot of anxiety about whether or not their child is having enough to eat or getting enough to eat. And that's going to be the basis for a lot of them saying things like eat more bite or you didn't eat enough. You can't do this. It really goes back to some parental anxiety. So support from responsive feedings. I want to say there are two really powerful-- OK, maybe three really powerful-- statements in these bullet points. One is be patient. Encourage children, but don't force them to eat. I was giving this presentation once and a family came up to me and said, this is really great. This is exactly what we don't do. And we all struggle with our weight. How do I help my older children now? And they were teenage years. Start small. Be patient. This is an entirely different way of thinking about the feeding environment, especially for young children, that parents are primed to do. And so this will take a lot of time. The second powerful thing I like about these bullet points is that parents are teachers, too, and help them-- and Jodie will talk about this here in a bit-- but help them think about ways that they can use their role as a teacher during meal times to integrate-- you know, like talk about new foods and what that means to their family in terms of this is my grandmother's recipe. It's really special to me. Or talk about colors or their favorite book or your recent home visit. How can you kind of integrate this in meal time and empower the parents to support their child's learning? 

And give children enough time. Now, these 30 minutes for a snack and 45 minutes for meals, it's just a

guideline. It might look very different. It may not be possible for every family to do 45 minutes at meal time. But to give them some idea that they're going to need to have more than 10 to 15 minutes for dinner time and let them have those clear expectations is kind of hopeful. So I think we talked about these questions. How does your child describe when they are full? So we did it for infancy and these are for the older ones. But again, really strategize how to create a meal time routine that works for them, which is why home visitors are so powerful. You have that relationship with families. You can spend that time learning more about their routine and their barriers and struggles and interject some of these strategies into that that would really work for them and resonate well with them. And then find ways to involve their child in meal times, which I talked about a little bit. And so since we are running a little bit late, I'm going to turn it over to Jodie, but we'll be sure to answer questions here at the end. 

Jodie Fishman: Thank you so much, Florence. That was so much great information. I'm going to just give you a tiny introduction about myself so that we can continue moving forward with the rest of our concept. My name is Jodie Fishman and I work at Zero to Three and do a lot of work on behalf of the National Center for Early Childhood Health and Wellness on a number of topics for home visitors, so including with responsive feeding. And my background is in maternal and child health. I spent several years working on a program for the HHS Office on Women's Health, called BodyWorks, which was a healthy lifestyle program for families, and then also working on Text for Baby, a national text messaging program for pregnant women and new moms where we provided information on a number of topics, but that did include feeding. 

And then, as Florence mentioned, the work that has helped me the most in this area is being a mom to three little ones -- five, three, and one. So I definitely learned the most about responsive feeding in that environment, in my home environment. So I wanted to start by exploring the role that family meal time can play as a learning opportunity to support child development. Meal times can be a logical supplement and a support to the weekly lessons plan that you build with families. And I think it's helpful to consider the skills practiced during meal time within the context of everyone's favorite, the early learning framework. So for example, how does mealtime support social and emotional development, or cognition, or motor and physical development, or language? 

The next few slides are going to give several examples of how meal time can support all of these domains of early learning. And more importantly, they can support your early learning goals targeted within your lesson plans each week. So for example, you may be working with a family whose goal is to develop their 2-year-old's language development. And while you know that they might be spending a lot of time with other activities on that in a week, meal times are this tangible, identifiable time that families can support their child one on one with those skills. So here you can see some information about mealtimes in early infancy and the early style learning framework. And we know that mealtime in early infancy is very different than with toddlers and preschoolers, or even in late infancy. And Florence talked about before introducing solids, infants are fed only breast milk or formula for the first year, and on demand. But however, as Florence mentioned, these feedings can still be learning opportunities. So when a caregiver is holding a baby and making eye contact, they're forming a relationship. They're building that social and emotional functioning. 

And we often know that an infant communicates their hunger and satiety in the language that they have available. So when the caregiver is listening and responding to the communication, the infant is learning that this is a trusting and supportive relationship. And the caregiver can help build language skills by talking to the infant during feeding, sharing words, facial expression, laughter. That all supports cognition and language develop. And in time, those infants will build the motor skills that can be supported during meal time. So they'll learn to hold their own bottle, they'll sit up without support. And they'll start practicing those fine motor skills, such as grasping small pieces of food, hand-eye coordination, starting to use objects like utensils. And so the caregiver can really use meal time as an opportunity for all of these learning domains in infancy and beyond. And we know, as I mentioned, that as infants grow, they reach different feeding milestones. So for example, the ability to sit without support. And as foods are introduced, they begin to develop fine motor skills. They're manipulating utensils. They're developing that pinch or grab around nine months. And mealtimes are a perfect opportunity to practice those skills by giving them small food items such as fresh fruit or vegetables cut up in small pieces, something soft. No choking hazard. And additionally, this is a great opportunity to explore textures of different foods, shapes, colors to make it really interesting and give them lots of different foods to choose, but also choose to look at to see different colors, shapes, textures, and that kind of thing. 

And we know that many providers, as Florence also mentioned, offer sign language as a method for building the communication skills. And that adds to their cognition, as well. And the social emotional bond and that trusting relationship continues to be supported during meal time as the children grow. And then we have meal time with toddlers. As infants grow into toddlers, they can begin to interact more with their caregivers and they begin building the skills needed to participate in more family style meals. So they begin to learn mealtime execution like the timing of the meals, table manners, how they interact throughout a meal, what to do when the meal is over. 

And this is also a great opportunity for families to kind of sit back and relax and share stories from their own childhood, to talk about their days, to play make believe, to get creative and engage with their kids. I think both of us have mentioned, you know, food is more to us than just nourishment. So it often ties back to our family culture, our community, even ethnicity. And mealtimes are really this great opportunity to share our culture with our children and cultivate a connection in the family and in the community. You can also reinforce the lessons with toddlers by cutting foods into shapes, engaging your child in counting food items, like perhaps asking them, how many apple slices do you have, or how many would you like? I know my three-year-old wants a cheese stick in his lunch every single day, and every morning, I ask him, how many pieces should I cut it into? And then when he goes to school, he sits and counts the pieces and tells me at the end of the day how many there were. Sometimes, it's a surprise. Sometimes, he decides. So kind of coming up with fun ways to engage your kid around what they're eating. 

You can also offer different textures or cooking methods, especially with new foods that maybe your child won't accept initially, such as a big sweet potato versus mashing it, versus cutting it into long strips for dipping, or making it into sweet potato fries. Experimenting with how your child likes it prepared using different textures and shapes. And then again, as Florence talked about, involving your children in preparing the food. So as their skills develop, maybe they're not ready to cook. Maybe they are. But they could set the table or wash the fruits and vegetables. They can stir or pour or mix or even help measure. And it might help reminding parents that these strategies not only help their child learn, but they make the meal time more fun. And this can be an important strategy with picky eaters. And then quickly, I'll touch on mealtimes with preschoolers. Just keep this moving along. We know that these are also an opportunity for learning. So as the children grow older and mature, families can get even more creative. They can use clear pictures and glasses to help with logic and math skills and spatial awareness. And they can even be invested with more responsibilities at meal times, as well. 

So within this context, meals can offer support. Gold develops within the family engagement framework. And the perimeter of impact areas include building family partnerships and teaching and learning. So as a home visitor, you're partnering with a family to build specific learning goal which can be supported during meal time. And in addition, you can also build family health goals, such as eating meals regularly as much as possible. As a family, talk about turning off screens, serving healthier foods. Those are all commonly reflected in your family partnership agreement.   00:46:03,567 --> 00:46:10,266 And then here you'll see some questions and statements to help families. So families may not think of meal time as an opportunity to teach their children anything. You know, they may be thinking of them just as a time to eat. So you can help families think of concrete ways they can support your lesson plans. You can look for simple things that they can do during their next meal time, such as serve a red food if your lesson plan involves identifying red things. Talk about a character in a new book you bought. 

Incorporate a new word or maybe just some positive encouragement to their child. Meals are sometimes a rare opportunity for families to sit and get to know one another, as Florence said, without distractions or with minimal distractions, or minimal time commitments and minimal outside stressors. So just really thinking through helping them use this time as an opportunity for bonding and enjoying their children. And this is the question that Florence was referring to earlier. How do you make your child laugh at meals? This is such a great question. Some other ones here -- what words do you use to describe the foods you serve? How do you introduce new foods to your child? 

These are some simple questions you might use with families just to introduce the learning opportunities withed shared meal time. And then again, we really just want to drive home that message that meal times are about more than just food. You know, we know that by age two, children have begun to assume the eating habits of their family. And we also know that we are seeing vegetable consumption plummet. We're seeing french fries and other foods come onto the family table as early as nine months of age. And this means that our Early Head Start services, and particularly, literally, our home base and family engagement services, are really vital to help parents build healthy habits for their families. And it really is never too early to start. And so like I mentioned, we know that children are not eating enough fruits and vegetables, if any, which is the scary, scary thing. 

And the ones that they are eating tend to be starchy vegetables, such as potatoes in the form of french fries. We know that children are consuming too many sugary drinks. Almost 30 percent of 12- to 24month-old parents reported giving them a sugary drink every day. And we also know that our young children are spending a lot of time in front of screens and not getting enough sleep. And both of those things can affect the way they eat, what food we want to eat, how we're sleeping, and how we're learning. So we really want to help families use mealtimes as an opportunity to build healthy habits. We want to get them to introduce and encourage their children to try new foods. All the research shows that continued exposure to a food will increase the likelihood that the child will eventually try it and consume it. And some research has shown that when preschool children were given opportunities during meals to observe other children choosing and eating vegetables that the observing child didn't like, their intake of those vegetables that they didn't like increased. 

And this happens with lots of parents, as well. Role modeling with new foods and healthy foods is an important part of building those healthy habits. But unfortunately, the reverse is also true. So we know that if a child sees adults modeling unhealthy eating habits, those are the habits that they're likely to adapt themselves. Meal times also are a time to provide education on nutrition, such as talking about healthy foods, talking about food groups. Kids at these ages love group or categorize things, so teaching them the food groups from my plate or asking them to group food according to color or shape. And then it's also time to teach the family about serving sizes, which is a really important piece of this. And this can be difficult for families because we're often tempted to consider serving sizes for a child the same that they would be for an adult. And so we want families to know what a healthy recommended serving size is for both the adult and the child. And so for that reason, we're going to look at the appropriate serving sizes, too, for infants, toddlers, and preschoolers. Why are family meals important? The benefits to children are numerous. They build independence. We talked about parent provides, child decides. It gives them a chance to be in control of what they're putting in their body, while the parent is in control of what to put in front of them. They provide structure. 

They help build expectations of what should occur at meal time. And they help with those fine and gross motor skills. They help with the development of language and social skills. I'm going to speed through this just a little bit because we're running low on time and I want to be able to share some of our resources that we've created with all of you. I think we've talked a lot about the benefits for families, as well, that you can see on this screen here. And then, as Florence mentioned, I did want to stop and pause and talk about food insecurity because food insecurity during a child's first year threatens their brain development and children in food insecure families are likely to have unhealthy diets, inconsistent eating habits. And all of that places them at risk for cognitive impairments and other long term problems, including obesity. And food insecurity is not the same as hunger. Food insecure families are often able to avoid hunger because they're choosing cheaper and more filling types of food over nutritious foods, which are more costly. So food insecurity has been linked to nutrient deficiencies that lead to learning and development problems, especially among infants and toddlers. And some of the longer term effects of food insecurity include lower achievement in school, emotional problems, and more health problems. 

So a family is considered food insecure if they frequently are unable to afford balanced meals, reduce the size of meals due to lack of money, and reduce the quality and variety of their normal diet due to lack of money. Studies show that children that come from food insecure families, compared to their peers, are more likely to have fair or poor health, rather than good or excellent health, more likely to spend time in the hospital, more likely to have problems in cognitive, language, and behavioral development. And so you'll see on the screen some of the assessment questions that you can use to ask families. And as a home visitor, we really want to make sure that families are connected with support. So that could be food pantries, or SNAP, or WIC, or any other local resources, as well. And as a home visitor, you have this unique opportunity. You are able to work closely with families to support healthy eating habits and role modeling and meal time routines. I just want to stop and pause there and make sure we're giving you all of this information that can be helpful to so many professionals working with young children. 

I want to drive that point home that as a home visitor, this opportunity is really unique because you can be in a family's home and get a really good sense of what meal time is like. And so now I wanted to quickly, because we're running out of time, just let you know about a brand new free set of resources that are targeted specifically for home visitors. It's going to be a brand new suite of materials on responsive feeding. And these will live on the ECLKC. 

They will be offered in both English and Spanish. They will be posted next week. They're not currently live. So just to let you all know if you go looking for them today, you won't find them, but they will be there next week. And what's going to be included in this is one five-minute video, which I'm going to try to show you really soon. So we'll try to squeeze that in before the end of this webinar. There will be an audio file of that, which is kind of a podcast file that you can listen to on the go. And then there are going to be three main handouts that you can download. 

One is called What to Know Before You Go. One is called During the Visit. And then there is an additional resource that can be downloaded and has leave behind documents for families on responsive feeding. And then in addition, there are three recorded PowerPoints on responsive feeling that you can use and share with colleagues to kind of give them an overview of responsive feeding, as well. So this is just what they look like. These are the documents for home visitors. And then this is the Leave Behind Resource for Expectant Families. that's on Healthy Feeding from the Start, and that's a resource. Clean Language offered in both English and Spanish that you can leave behind with families that you're working with. I'm going to try to show this video. And then, probably, that will be the end. I realize we're short on time, so after that, hopefully, we'll have time for a couple of questions. One note about the video, as people mentioned, the audio for this will come only through your computer. So if you're listening through your phone, you won't hear it through the phone. You will only hear it through your computer. So here we go.  [Video clip begins]

Narrator: Welcome to PD on the Go for home visitors. Learn 5 Things in Five Minutes: Supporting Healthy Eating at Home. As a home visitor, you have the opportunity to observe and maybe even be a part of a family's meal times. This video presents five key ideas to guide you in helping families make the most of these mealtime moments. 

Key idea numberone: respect families' beliefs and values about food. Food can be a sensitive topic. Take the time to listen to parents' thoughts, feelings, and perspectives about feeding. When you show you are listening, parents may be more open to your suggestions. 

Key idea number two: encourage responsive feeding. Responsive feeding means that adults follow children's' cues about eating healthy food. They will tell you how much and which healthy foods they want to eat. Parent provides. Child decides. Parents are responsible for offering healthy meals and snacks to children. Children are responsible for deciding whether they will eat and which and how much of the healthy foods they would like to eat. This approach is responsive because it encourages children to listen to their body signals of hunger and fullness, develop self control regarding how much food they will eat, build skills such as picking up foods or using utensils, actively participate in meal and snack times, and effectively communicate their need for food. All of these skills help children learn to make healthy choices as they grow.

Woman: Good job.

Narrator: Key idea number three: avoid forcing children to finish the food on their plate. Forcing children to eat usually leads to children eating less. Controlling what and how much a child eats may affect a child's food preference, ability to listen to their own hunger and satiety cues, and the amount of food consumed. Using food as a reward or punishment teaches children to ignore their body's cues of hunger and fullness. Food is a basic need and shouldn't be mixed up with discipline. 

Key idea number four: establish a positive social environment at meals. There are many ways parents can make meal times a joyful bonding experience. Encourage families to share stories about their days, their family and friends, and their experiences together. Parents can provide ways for children to be part of food preparation. They can help wash fruits and vegetables, stir, pour, mix, and even measure. Children can help to set or clear the table. These activities build a child's confidence, self-esteem, and connection to the family.

Woman: You could either sit at that table, or you can sit here.

Narrator: Parents can also serve as positive role models for healthy eating. Encouraging picky eaters to try new foods or a food they don't think they will like can be frustrating. Research tells us a child may need to try a food 10 to 15 times before they will accept it. We also know when children observe others eating foods they typically refuse, they become more willing to try those foods. 

Key idea number five: meals are a time to learn new skills. Parents can nurture thinking skills by naming the shapes of different items on the table, like the plate that is a circle. They can help children count pieces of food on their plate or count cups or napkins on the table.

Woman: Sophia, can I have one cracker, please? Thank you.

Sophia: Can I have one cracker, please?

Narrator: Parents can also nurture children's' language skills by naming the colors of different foods. Introduce new vocabulary words like delicious, juicy, or crunchy to describe the food. -Woman: Oh. Child: I liked [Inaudible].

Woman: I like broccoli, too. It's one of my favorite vegetables. [Inaudible] grows broccoli? And fava beans. Ezra loves fava beans.

Narrator: Mealtimes also build social emotional skills. Children can learn the back and forth of conversation and the feeling of connection with family at meal time. And that's five ideas in five minutes. To learn more about responsive feeding, check out PD on the Go for home visitors to access other resources. And please visit the National Center on Health and Wellness' portal on the Early Childhood Learning and Knowledge Center for more resources to use in your work with families. 

[Video clip ends]

Jodie: All right. So I know we are out of time. I just want to mention that this video and all of the other resources that I mentioned will be available next week on ECLKC, and we will send an email to everyone who signed up for the webinar today once it's available to let you know how you can access those. So again, thank you very much for joining us. And as April mentioned, if you have further questions, I think we can move the conversation to MyPeers and hopefully help answer some of those there.

 April: Thank you all so much for joining. Please stay tuned for your post-webinar evaluations, and remember at the very bottom of the evaluation is where you can get your certificate. But if you have trouble with that, we'll get you an email at the end of the day with another opportunity to print your certificate. So we'll be in touch with everyone again next week with the link to these resources, and thank you all for joining us today. We'll be in touch.

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