Patient Care: This chapter will address the following American College of Graduate Medical Education competencies: patient care, medical knowledge, and interpersonal and communication skills.

Anticipatory guidance around feeding and activity behaviors is an important component of well-child care and can result in increasing a family’s confidence in managing their child’s behavior. This chapter will help the pediatric health care provider implement this guidance with families of infants and toddlers.

Medical Knowledge: This chapter will help pediatric health care providers understand the relationship of development to feeding and activity behaviors and the importance of being able to help parents set expectations for infant and toddler behavior, create appropriate boundaries, and develop a responsive parenting style.

Interpersonal and Communication Skills: This chapter will help the pediatric health care provider understand how to gather information about the family system in a nonjudgmental and empathic manner and lay the groundwork for discussion of effective positive lifestyle change.

A tremendous amount of development occurs in the first 2 years of life and these key developmental stages inform parent expectations and parenting practices. Communication or language, cognition, social development, and physical development are discrete but interdependent areas of development and are most effectively acquired during a critical period, built on existing knowledge or skills (scaffolding).¹ It is important for the pediatric health care provider to provide guidance to parents that the specific ages at which children acquire certain skills can vary by individual, but that in the cases of significant deviations from the norm, the pediatric health care provider can provide referrals for additional assessment and intervention.

Language

Infants initially communicate about their basic needs via crying out, and attachment theories suggest that consistent and prompt responding by providing nurturing and basic needs (ie, food, safety, shelter) in response to crying will help children establish a healthy sense of safety.² Crying out does not always mean a child is hungry, and learning to soothe children in other ways besides providing food is an important step toward establishing healthy eating routines and healthy self-soothing skills. The same principle of responsive parenting is true for older infants and toddlers (6 months-2 years). However, toddlers use more specific communication (eg, gestures, words) to indicate something they want, though they may not yet have the skills to accurately understand what they need. For example, a 15 month old gesturing for and saying “juice” may be thirsty, bored, upset, or hungry. Thus, balancing the communication demands of a child with setting appropriate boundaries is important. Pediatric health care providers can help families carefully balance requests for food due to hunger versus other needs by monitoring the child’s growth, assessing specific eating patterns in the home, and assessing behavioral patterns between parents and children.

Cognition

Children’s cognitive development changes rapidly in the first 2 years, with new skills emerging monthly, or even weekly.^3,4 Initially, infant behavior is primarily reflexive. Once an infant reaches 4 to 6 months of age, he or she begins exploring the world in terms of cause and effect. As a child nears 1 year, object permanence emerges, when a child understands that an out of sight object still exists. This time period is when a child begins to ask for people, food, or toys that are not visible (eg, crackers in a cabinet). From 12 to 18 months of age, children begin to develop curiosity and experiment with getting different results. In their second year, with this new curiosity and budding ability to be creative, they may begin to problem solve and explore boundaries (ie, say “no”). Young children’s attention span is also variable and tends to increase in length as long as another person is engaged and responding.⁴ Infants typically attend to a novel stimulus for only a few seconds at a time and are primarily concerned with sensory input (eg, being hungry, a sound, something in their immediate view). Children who are 1 year old may attend to an engaging activity for several minutes, while 2 year olds may attend for 10 minutes or possibly more.

While children are learning these concepts, they are exploring them in practice. For example, between 4 and 6 months, they may toss a bottle to see if it makes a thud sound on the floor. A 12 month old may throw food on the floor repeatedly to explore cause and effect or object permanence: (1) when I throw it, can I cause a parent to respond (or not, if a parent chooses to limit their reactions), or (2) when I throw it, does it go away or does it still exist on the floor. Pediatric health care providers should provide parents with guidance about how toddlers learn through repetition so that they will expect activities and behaviors to be repeated over and over again (even those which are frustrating to the parent).

Social

Infants and toddlers rely heavily on modeling by others, because imitation emerges as a primary modality for learning by 3 to 6 months of age.² Just as an infant begins to engage in back and forth mimicking facial expressions and babbling, he or she absorbs characteristics of every behavior they witness (eg, sitting at a table to eat, using an indoor voice, putting on seatbelts, etc). Children younger than 2 years are not expected to demonstrate theory of mind, or the ability to consider how others might be thinking or feeling.^2,4

Physical

Physical development in the first 2 years of life is also remarkable in its scope, and includes perceptual development (vision, hearing, etc), as well as ambulation and motor control. A complete review is not included here, though careful attention to the physical abilities of a child, with an eye toward developmentally appropriate expectations, should be considered when making recommendations about healthy lifestyle choices and parenting strategies.

It is important to remember that many challenging behaviors represent an area in which the child is learning a new skill, not an intentional attempt to defy or challenge parents. The pediatric health care provider should monitor that parent expectations match the “next steps” in a child’s development, and that the child has foundational skills before learning more difficult skills. Infants and toddlers rely on adults to model and make healthy decisions for them, and providing guidance about typical development is an essential role for the pediatric health care provider in order to guide effective parenting strategies.

While parents of newborns often feel like there is no schedule or routine that would describe their child’s behavior, it is beneficial for the pediatric health care provider to counsel regarding the benefits of routines starting at the 2-month well-child check (WCC). Parents should be counseled regarding establishing consistent routines for sleeping by this point. The specifics of the bedtime routine are not quite as important as the benefits of bonding, consistency, and opportunities for calming the baby for sleep. Parents are encouraged to develop a nighttime ritual or routine that involves a consistent, predictable pattern of behaviors each night to signal the child that it is time for bed. For example, the parents may dim the lights, give a relaxing bath, read a book, and sing a song or say a prayer with their child before placing them in their bed. To establish healthy sleep habits, it is important that this routine end with the child in his or her bed drowsy but not fully asleep and that feeding not be something that occurs immediately prior to being put into bed.⁵

Establishing routines and schedules for naptime and bedtime becomes especially important as the toddler years begin. As children become more mobile, they can have more difficulty settling into bed. Toddlers may not be as interested in sitting still to read, but it is important to maintain a consistent routine that helps signal the child that bedtime or naptime is nearing.⁵ Separation anxiety peaks at 10 to 18 months of age, and children who may have been doing well with routines may suddenly protest,⁶ making it more difficult for parents to separate at bedtime. It is important for parents to set limits about how many books will be read, how many hugs will be given, and so on. Pediatric health care providers should counsel parents to remain as consistent as possible with bedtime routines and that if they get off track due to illness, vacation, or family life changes, it is okay to just restart the routines instead of feeling stuck in habits that the parent would prefer not to have (eg, needing to remain in the child’s room to help him or her fall asleep, going in to rock the child back to sleep during the night, allowing the child to come into bed with them, etc).⁵

Counseling parents regarding establishing routines for eating should occur at the 2-, 4-, and 6-month WCCs and continue throughout developmental transitions (eg, transition to solid foods, transition to table foods, decrease in appetite, etc). Eating routines are important in allowing children to experience the feeling of satiety and hunger as well as to handle the food jags that are expected during the toddler period. Specifically, it is beneficial for parents to know that toddlers will have another opportunity to eat in 2 to 3 hours if they are being resistant to eating any of the foods that have been offered at a given meal. As noted in Chapter 6, toddlers need to understand where and how they will eat. It is ideal for early habits to be established, such as everyone eats together, the toddler sits in a high chair or at the table, the toddler is not allowed to carry around bottles or cups of milk in between meals. These routines allow parents to serve as critical role models of healthy eating that are so important for development of healthy habits.

It is important to remember that counseling parents about establishing routines for eating and bedtime should start as early as the 2-month WCC. Consistency and predictability are especially important for toddlers and can prevent behavior problems from occurring. The specifics of the routine are not as crucial as having a routine.

Parents play a central role in promoting development of healthy child habits through the establishment of clear routines and boundaries. With the establishment of clear routines and boundaries, children are aware of what the expectations are for their behavior. Inadvertently, parents can develop unhealthy habits and responses to child behaviors; for example, when infants display distress or toddlers misbehave, parents may turn to food to soothe their child or stop temper tantrums.^7,8 In fact, research has shown that sugar in foods can immediately reduce infant distress.⁹ This phenomenon rewards parents for using an unhealthy strategy for managing child behavior. Over time, feeding in response to distress may lead to an increase in child weight status. Therefore, learning effective strategies to calm or discipline a child may assist with obesity prevention and provide parents with a greater sense of self-efficacy to implement other healthy lifestyle recommendations.

Discussion about how to respond to infant distress should take place from birth. One survey showed that 48% of parents reported that they would seek advice about discipline from pediatricians.¹⁰ Engaging parents in a discussion about the strategies they are currently using to decrease infant or toddler distress provides an opportunity to discuss challenges and offer possible solutions. Some evidence suggests that parents are more likely to ask for help when they are having difficulty with managing their child’s behavior and/or feeling increased parenting stress.¹¹ If anticipatory guidance about discipline and how to handle distress is provided at WCCs, it is possible that parents may feel better equipped to deal with challenges as they occur.

The American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family¹² published a conceptual framework describing 3 main components of effective discipline, including (1) supportive parent-child relationships, (2) reinforcing desired behaviors, and (3) using extinction strategies or consequences for decreasing undesired behaviors. Discipline strategies vary depending on the age of the child. During infancy, parents are learning how to respond to their child’s cues for discomfort.¹³ As routines are developed for feeding and sleep, parents begin to learn how to identify when an infant appears distressed due to hunger versus nonhunger (eg, a wet diaper, general fussiness, etc). Pediatric health care providers can counsel parents about how infants signal distress, as well as how to use alternative methods to food to soothe infants for nonhunger-related distress or fussiness. In fact, using food to soothe infant and toddler distress has been shown to be associated with lower ratings of parenting self-efficacy, children with higher temperamental negativity, and higher child weight status.¹⁴ It has been hypothesized that using food to soothe decreases a child’s ability to self-regulate food intake, which may increase the risk for obesity in childhood. Therefore, it is recommended that pediatric health care providers advise parents to avoid using food to comfort or calm infants or toddlers when distressed. Instead, alternative methods of soothing infants may include holding or swaddling,^{15, 16, 17} whereas distressed toddlers may benefit from redirection to a pleasant activity.

As young children begin to walk, explore, and interact with their social and physical environment, discipline begins to incorporate setting boundaries. This enables young children to learn about expectations for appropriate behavior. Boundaries associated with obesity prevention for infants or toddlers may include creating family rules for the location of eating. For example, a common message delivered to parents is that all food consumed at home should be served in the same location.¹⁸ For many families this would involve sitting at the kitchen or dining room table in either a high chair or booster seat for all meals and snacks. Families are encouraged to eat together, with adults eating the same food as children to create the opportunity of modeling healthy eating behaviors. Differential attention may be used during the mealtime or snack to encourage the child’s trying of healthy new foods by displaying positive affect and specific praise, and ignoring attempts by the child to push new food away.

It is important to remember to introduce parents to nonfood ways to soothe and calm infants or toddlers when distressed, and to engage parents in a discussion about how to create boundaries for eating locations. One strategy to reinforce positive and healthy infant and toddler behavior is to use differential attention.

Dealing with mealtime behavior challenges

One of the most important ways the pediatric health care provider can aid parents in navigating mealtime behavior challenges is in normalizing them. When parents know what to expect, the behavior challenges should be less frustrating and parents may be more able to handle them. Parents who expect toddlers to have a declining appetite and to assert their independence through demanding certain foods, rejecting previously desirable foods, and making big messes with foods can be more patient when these things inevitably occur. They may also be more likely to persist in serving a healthy well-balanced diet and avoid becoming a personal chef, making whatever the child demands. It is important for the pediatric health care provider to emphasize that the parents role is to provide well balanced meals and snacks in appropriate portions, and that it takes between 10 and 15 tries before foods may be accepted.¹⁹