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Maternal Distraction During Breast- and Bottle Feeding Among WIC and non-WIC Mothers

      Abstract

      Objective

      To explore the prevalence and correlates of maternal distraction during infant feeding within a sample of mothers enrolled or not in the Special Supplemental Nutrition Program for Woman, Infants, and Children (WIC).

      Design

      Mothers kept diaries of their infants' feeding patterns.

      Participants

      Mothers (n = 75) with infants aged ≤6 months.

      Main Outcome Measures

      Within the diaries, mothers recorded what else, if anything, they did during the feeding. Mothers also completed questionnaires on demographics, feeding styles, and infant temperament and eating behaviors.

      Analysis

      Mothers' responses were coded into thematic categories. Feedings were classified as distracted when the mothers reported doing something other than feeding and/or interacting with the infant. Logistic regression was used to explore whether mothers exhibited different levels of distraction when breastfeeding (BF) vs bottle feeding. The researchers used multiple stepwise regression to explore associations between distracted feeding and characteristics of mothers and infants.

      Results

      Distractions were reported during 43% of feedings; 26% involved technological distractors. Mothers who were multiparous and perceived that their infants had greater appetites reported greater levels of any distraction during feeding. Mothers who were of racial/ethnic minorities, adhered to laissez faire feeding style, had younger infants, and perceived their infants to have lower food responsiveness and greater appetite reported greater levels of technological distraction. Being enrolled in WIC was not associated with mothers' levels of distracted feeding.

      Conclusions and Implications

      Mothers reported a wide variety of distractions during both BF and bottle feeding; higher levels of distraction were associated with characteristics of both mothers and infants. Further research is needed to understand whether and how maternal distraction affects feeding outcomes. Awareness of such distractions and their potential impact would be useful to practitioners working with pregnant and postpartum women.

      Key Words

      Introduction

      A growing body of research highlighted the importance of caregiver sensitivity and responsiveness during feeding for promoting infants' abilities to self-regulate intake
      • DiSantis K.I.
      • Hodges E.A.
      • Johnson S.L.
      • Fisher J.O.
      The role of responsive feeding in overweight during infancy and toddlerhood: a systematic review.
      and healthy infant weight gain trajectories.
      • Farrow C.
      • Blissett J.
      Does maternal control during feeding moderate early infant weight gain?.
      In addition, caregivers' sensitivity and responsiveness in both feeding and non-feeding contexts help infants develop effective emotional, cognitive, and behavioral self-regulatory abilities,
      • Leerkes E.M.
      • Wong M.S.
      Infant distress and regulatory behaviors vary as a function of attachment security regardless of emotion context and maternal involvement.
      which are predictive of significantly better stress reactivity,
      • van Bakel H.J.
      • Riksen-Walraven J.M.
      Stress reactivity in 15-month-old infants: links with infant temperament, cognitive competence, and attachment security.
      lower risk for internalizing and externalizing problems,
      • Lyons-Ruth K.
      • Block D.
      The disturbed caregiving system: relations among childhood trauma, maternal caregiving, and infant affect and attachment.
      and lower risk of obesity and related comorbidities
      • Miller A.L.
      • Rosenblum K.L.
      • Retzloff L.B.
      • Lumeng J.C.
      Observed self-regulation is associated with weight in low-income toddlers.
      • Power T.G.
      • Olivera Y.A.
      • Hill R.A.
      • et al.
      Emotion regulation strategies and childhood obesity in high risk preschoolers.
      during later life. Thus, it is well established that an important foundation for promoting healthy development during early childhood is the promotion of caregivers' sensitivity and responsiveness during caregiver–infant interactions. However, the Institute of Medicine
      • Institute of Medicine
      Early Childhood Obesity Prevention Policies.
      and others
      • Lumeng J.C.
      • Taveras E.M.
      • Birch L.
      • Yanovski S.Z.
      Prevention of obesity in infancy and early childhood: a National Institutes of Health workshop.
      highlighted the surprising paucity of research aimed at understanding how to promote caregivers' sensitivity and responsiveness within feeding contexts and the need for more research in this field. This is especially true for low-income and racial/ethnic minority caregivers, who are more likely to use non-responsive feeding practices
      • Gross R.S.
      • Fierman A.H.
      • Mendelsohn A.L.
      • et al.
      Maternal perceptions of infant hunger, satiety, and pressuring feeding styles in an urban Latina WIC population.
      • Baughcum A.E.
      • Burklow K.A.
      • Deeks C.M.
      • Powers S.W.
      • Whitaker R.C.
      Maternal feeding practices and childhood obesity: a focus group study of low-income mothers.
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      • Mendelsohn A.L.
      • Fierman A.H.
      • Hauser N.R.
      • Messito M.J.
      Maternal infant feeding behaviors and disparities in early child obesity.
      and whose infants are at higher risk for rapid weight gain and obesity.
      • Polk S.
      • Thornton R.J.
      • Caulfield L.
      • Munoz A.
      Rapid infant weight gain and early childhood obesity in low-income Latinos and non-Latinos.
      • Pan L.
      • May A.L.
      • Wethington H.
      • Dalenius K.
      • Grummer-Strawn L.M.
      Incidence of obesity among young U.S. children living in low-income families, 2008-2011.
      • Ogden C.L.
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      • Kit B.K.
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      Prevalence of childhood and adult obesity in the United States, 2011-2012.
      Although there are many reasons why caregivers may exhibit low responsiveness to infant cues during feeding interactions, few studies examined how maternal distraction (eg, watching television [TV], using a mobile device) may affect infant feeding interactions and outcomes.
      • Radesky J.
      • Miller A.L.
      • Rosenblum K.L.
      • Appugliese D.
      • Kaciroti N.
      • Lumeng J.C.
      Maternal mobile device use during a structured parent-child interaction task.
      • Radesky J.S.
      • Kistin C.J.
      • Zuckerman B.
      • et al.
      Patterns of mobile device use by caregivers and children during meals in fast food restaurants.
      • Golen R.B.
      • Ventura A.K.
      Mindless feeding: is maternal distraction during bottle-feeding associated with overfeeding?.
      • Golen R.P.
      • Ventura A.K.
      What are mothers doing while bottle-feeding their infants? Exploring the prevalence of maternal distraction during bottle-feeding interactions.
      Research in older children and adults illustrated that distracted eating is a common occurrence
      • Matheson D.M.
      • Killen J.D.
      • Wang Y.
      • Varady A.
      • Robinson T.N.
      Children’s food consumption during television viewing.
      and that eating while engaging with technological distractions has an impact on meal outcomes, leading to lower awareness of satiety cues and overeating compared with meals when no distractions are present.
      • Brunstrom J.M.
      • Mitchell G.L.
      Effects of distraction on the development of satiety.
      • Long S.
      • Meyer C.
      • Leung N.
      • Wallis D.J.
      Effects of distraction and focused attention on actual and perceived food intake in females with non-clinical eating psychopathology.
      Few studies examined whether distracted feeding has similar and/or unique impacts on caregiver–child feeding interactions.
      Given the ever-increasing accessibility of handheld technologies and on-demand entertainment,

      Pew Research Center. Mobile technology fact sheet. http://www.pewinternet.org/fact-sheets/mobile-technology-fact-sheet/. Accessed April 6, 2017.

      even among lower-income, minority populations,

      Pew Research Center. The state of the digital divide. http://www.pewinternet.org/2013/11/05/the-state-of-digital-divides-video-slides/. Accessed April 6, 2017.

      Pew Research Center. U.S. smartphone use in 2015.http://www.pewinternet.org/2015/04/01/us-smartphone-use-in-2015/. Accessed April 6, 2017.

      combined with the large number of feedings required by young infants on a daily basis,
      • Fomon S.J.
      Nutrition of Normal Infants.
      it is possible that many caregivers regularly attend to distractors while feeding their infants as a means to cope with the large volume of time they must dedicate to feeding. Indeed, in a recent study of bottle-feeding dyads, mothers reported distractions during 52% of bottle feedings; almost one third of these feedings involved technological distractors.
      • Golen R.P.
      • Ventura A.K.
      What are mothers doing while bottle-feeding their infants? Exploring the prevalence of maternal distraction during bottle-feeding interactions.
      In addition, in a laboratory-based study, mothers who were distracted while bottle feeding their infants were significantly less sensitive to their infants' cues than were mothers who were not distracted.
      • Golen R.B.
      • Ventura A.K.
      Mindless feeding: is maternal distraction during bottle-feeding associated with overfeeding?.
      These previous studies also illustrated that tendencies toward distracted feeding were associated with certain maternal characteristics such as age and parity,
      • Golen R.P.
      • Ventura A.K.
      What are mothers doing while bottle-feeding their infants? Exploring the prevalence of maternal distraction during bottle-feeding interactions.
      and that associations between distraction and feeding outcomes may be moderated by dimensions of infant temperament
      • Golen R.B.
      • Ventura A.K.
      Mindless feeding: is maternal distraction during bottle-feeding associated with overfeeding?.
      such as infants' abilities to self-regulate (ie, orienting/regulation capacities) and levels of impulsivity (ie, surgency/extraversion).
      Because these previous findings focused solely on bottle-feeding mothers, further research is needed to understand whether similar levels of distraction are present in breastfeeding (BF) dyads and whether certain mother–infant dyads are more likely than others to engage in distracted feeding. To this end, the objective of the current study was to explore further the prevalence of maternal distraction within a sample of both BF and bottle-feeding participants enrolled or not in the Special Supplemental Nutrition Program for Woman, Infants, and Children (WIC). A secondary aim of this study was to examine whether maternal (ie, feeding mode, WIC status, education, race/ethnicity, parity, body mass index [BMI], feeding styles) and infant (ie, sex, age, weight status, temperament, eating behaviors) characteristics were associated with mothers' tendencies toward distracted feeding. Based on findings of previous research focused on distracted feeding,
      • Golen R.B.
      • Ventura A.K.
      Mindless feeding: is maternal distraction during bottle-feeding associated with overfeeding?.
      • Golen R.P.
      • Ventura A.K.
      What are mothers doing while bottle-feeding their infants? Exploring the prevalence of maternal distraction during bottle-feeding interactions.
      it was hypothesized that higher levels of distraction would be associated with greater maternal age and parity and lower levels of responsive feeding style. In addition, previous research illustrated that BF mothers exhibited greater tendencies toward responsive feeding
      • Wright P.
      • Fawcett J.
      • Crow R.
      The development of differences in the feeding behaviour of bottle and breast fed human infants from birth to two months.
      • Crow R.A.
      • Fawcett J.N.
      • Wright P.
      Maternal behavior during breast- and bottle-feeding.
      ; accordingly, it was hypothesized that bottle-feedingmothers would show greater tendencies toward distracted feeding than would BF mothers. Finally, given previous research illustrating the importance of maternal responsiveness for infants' developing abilities to self-regulate, it was hypothesized that greater levels of maternal distraction would be associated with lower general (ie, orienting/regulation capacity dimension of temperament) and feeding-specific (ie, food responsiveness and satiety responsiveness dimensions of infant eating behaviors) self-regulatory capacities for infants.

      Methods

      Participants and Recruitment

      Mothers (n = 75) who participated in infant feeding studies
      • Golen R.B.
      • Ventura A.K.
      Mindless feeding: is maternal distraction during bottle-feeding associated with overfeeding?.
      • Golen R.P.
      • Ventura A.K.
      What are mothers doing while bottle-feeding their infants? Exploring the prevalence of maternal distraction during bottle-feeding interactions.
      • Ventura A.K.
      • Golen R.P.
      A pilot study comparing opaque, weighted bottles with conventional, clear bottles for infant feeding.
      were asked to keep a diary of their infants' feeding patterns for 1–6 days (total number of records = 476; total number of recorded feedings = 2,982). Feeding record data for a subset of 41 formula-feeding infants were published previously.
      • Golen R.P.
      • Ventura A.K.
      What are mothers doing while bottle-feeding their infants? Exploring the prevalence of maternal distraction during bottle-feeding interactions.
      Inclusion criteria for infants were that they were: (1) healthy, (2) born full-term, (3) aged between birth and 6 months; and (4) not yet introduced to solid foods. Inclusion criteria for mothers were that they: (1) were aged 18–40 years and (2) did not have gestational diabetes or any complications during pregnancy or birth that led to infant feeding problems. Both BF and formula-feeding dyads were included in the current study. Participants were recruited through fliers posted in offices of the WIC BF support groups, libraries, coffee shops, and local pediatric offices, as well as through targeted Facebook advertisements. Mothers were provided $25 cash compensation for participation. All study procedures were reviewed under expedited review and approved by the institutional review board at California Polytechnic State University. Both oral and written informed consent was obtained from each mother.

      Procedures and Measures

      Mothers received feeding records via postal mail or e-mail. Through both verbal instruction by a research assistant and written instructions on the form, mothers were asked to record, for each feeding: (1) start and end time; (2) what was fed (eg, formula, breast milk from the breast, breast milk from a bottle); (3) amount fed (if possible); and (4) what else, if anything, they were doing while feeding their infants.
      Printed records were collected from all mothers during a laboratory visit several days later, when mothers also completed a demographic questionnaire. Mothers also completed the Infant Behavior Questionnaire–Revised Very Short Form, which assessed infants' levels of surgency/extraversion, orienting/regulation capacity, and negative affect (subscale scores ranged from 1 to 7)
      • Putnam S.P.
      • Helbig A.L.
      • Gartstein M.A.
      • Rothbart M.K.
      • Leerkes E.
      Development and assessment of short and very short forms of the infant behavior questionnaire-revised.
      ; the Infant Feeding Style Questionnaire,
      • Thompson A.L.
      • Mendez M.A.
      • Borja J.B.
      • Adair L.S.
      • Zimmer C.R.
      • Bentley M.E.
      Development and validation of the Infant Feeding Style Questionnaire.
      which assessed mothers' self-reported laissez-faire (example item: I think it is okay to prop an infant's bottle), restrictive (example item: It's important for the parent to decide how much an infant should eat), pressuring (example item: I try to get my child to eat even if she or he seems not hungry), and responsive (example item: My child knows when she or he is hungry and needs to eat) feeding styles (all subscale scores ranged from 1 to 5); and the Baby Eating Behavior Questionnaire,
      • Llewellyn C.H.
      • van Jaarsveld C.H.
      • Johnson L.
      • Carnell S.
      • Wardle J.
      Development and factor structure of the Baby Eating Behaviour Questionnaire in the Gemini birth cohort.
      which assessed mothers' perceptions of infants' levels of enjoyment of food, food responsiveness, satiety responsiveness, slowness in eating, and general appetite (subscale scores ranged from 1 to 5). All questionnaire subscales showed good internal consistency in this sample, with Cronbach α scores ranging from acceptable (α = .70–.79) to good (α = .80–.89): the Infant Behavior Questionnaire–Revised Very Short Form subscales ranged from α = .78 to .83, the Infant Feeding Style Questionnaire subscales ranged from α = .70 to .85, and the Baby Eating Behavior Questionnaire subscales ranged from α = .71 to .87.
      A trained research assistant collected weight and length or height measurements in triplicate for infants and mothers using an infant scale and infantometer (Models 374 and 233; Seca, Hamburg, Germany) and an adult scale and stadiometer (Model 763; Seca), respectively. Infant anthropometric data were later normalized to z-scores using the World Health Organization Anthro software (version 3.0.1). Mothers’ weight and height were used to calculate BMI (in kg/m2).

      Data Analysis

      Mothers' responses to the question What else, if anything, were you doing while feeding your infants? were sorted into thematic categories using constant comparison within the framework of grounded theory.
      • Charmaz K.
      Grounded theory: objectivist and constructivist methods.
      Before coding, the first author developed a coding manual with an initial list of themes found in previous research examining the prevalence of distraction among bottle-feeding dyads.
      • Golen R.P.
      • Ventura A.K.
      What are mothers doing while bottle-feeding their infants? Exploring the prevalence of maternal distraction during bottle-feeding interactions.
      Three trained coders independently coded all records based on the coding manual, but also identified additional themes not present in the previous research. Results were then reviewed and compared for validity, and any discrepancies in theme identification or coding were discussed. Inter-coder reliability was established by comparing the common coding of a total of 10 records by all coders. Cohen's kappa for correspondence among coders was >0.80, indicating good reliability among coders.

      Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33:159-174.

      After coding was complete, themes were used to classify feedings into 2 categories: (1) mother was distracted (eg, watching TV, using a computer) vs (2) mother was not distracted (eg, nothing was specified, interacting with the infant). Distractions were also further classified into technological (eg, watching TV, using a computer, smartphone, or tablet) vs not (eg, reading, doing housework). To obtain a measure of each mothers' intensity of distracted feeding, the percentage of feedings during which the mother reported any distraction was calculated for each mother (= [number of feedings in which a distraction was reported/total number of feedings reported] × 100). Similarly, the percentage of feedings during which the mother reported technological distractions was calculated for each mother (= [number of feedings in which a technological distraction was reported/total number of feedings reported] × 100).
      All quantitative analyses were conducted using SAS (version 9.4; SAS Institute, Inc, Cary NC; 2013). Descriptive statistics were calculated to summarize sample demographics, mothers' frequency of different activities during reported feedings, and distracted vs not distracted feeding. Characteristics of participants who were or were not enrolled in WIC were compared using ANOVA and chi-square tests of independence. Mixed-effects models were used to examine associations between mothers' reported feeding durations and reports of any type of distraction or technological distraction during feeding, while also controlling for within-person correlation among repeated measurements of feeding durations and distractions.
      To explore whether mothers exhibited different levels of distraction when they were BF vs bottle feeding, the researchers used logistic regression with estimation via generalized estimating equations to determine whether feeding mode during each recorded feeding predicted the probability of mothers' reports of distracted vs not distracted feeding. Logistic regression models accounted for the within-person correlation among repeated measurements for valid estimation of associations between feeding mode and types of distraction, and associated SEs.
      To explore associations between distracted feeding and characteristics of mothers (ie, feeding mode, WIC status, education, race/ethnicity, parity, BMI, feeding styles) and infants (ie, sex, age, weight status, temperament, eating behaviors), multiple stepwise regression was used to determine the combination of infant and maternal characteristics that best predicted mothers' intensities of any distractions and technological distractions during feeding. Categorical variables were dummy coded before inclusion in regression models (ie, feeding mode, mothers' education level [high school degree or less vs some college or college degree], mothers' race/ethnicity [white vs black, Hispanic, or other]). In addition, all assumptions for multicollinearity of predictors, homoscedasticity, normality of residuals, and linearity were assessed before all linear regression analyses. When applicable, results are presented as percentages (n) or mean ± SD. P < .05 was used to indicate significant differences.

      Results

      Sample Characteristics

      Table 1 summarizes sample characteristics for mothers enrolled or not in WIC. As illustrated in Table 1, infants enrolled in WIC were significantly younger and had significantly higher weight-for-length z-scores than did infants not enrolled in WIC. Mothers participating in WIC were significantly younger, had significantly higher BMI, and had more children than did nonparticipating mothers. Similar to national data on characteristics of WIC participants,
      • Thorn B.
      • Tadler C.
      • Huret N.
      • et al.
      WIC Participant and Program Characteristics: Final Report 2014.
      mothers enrolled in WIC reported significantly lower family incomes and education levels than did mothers not enrolled in WIC and greater proportions of mothers who were enrolled were racial/ethnic minorities and were formula/bottle feeding compared with those who were not enrolled in the program. Perceptions of their infants and their feeding styles of mothers enrolled or not in WIC also differed: mothers who were enrolled in the program reported that their infants had significantly lower levels of negative affect, satiety responsiveness, and slowness in eating, and greater enjoyment of food compared with mothers who were not participating in WIC, and also reported more restrictive and less responsive feeding styles.
      Table 1Sample Characteristics by Enrollment in WIC
      Data are from mothers enrolled or not in WIC (n = 75) with infants aged ≤6 mo who participated in infant feeding studies
      CharacteristicMothers Enrolled in WIC (n = 46)Mothers Not Enrolled in WIC (n = 29)χ2 or F
      Infant characteristics
       Sex, female (%)54 (25)48 (14)0.26
       Age, wk14 ± 718 ± 75.72
      P < .05
       Weight-for-length z-score1 ± 10 ± 110.47
      P < .01 for difference between mothers enrolled or not in WIC.
       Temperament subscales
      From the Infant Behavior Questionnaire–Revised Very Short Form30 (possible score range: 1–7)
      Surgency/extraversion4 ± 15 ± 11.41
      Orienting/regulation capacity6 ± 16 ± 11.06
      Negative affect3 ± 14 ± 110.96
      P < .01 for difference between mothers enrolled or not in WIC.
       Eating behavior subscales
      From the Baby Eating Behavior Questionnaire32 (possible score range: 1–5)
      Enjoyment of food5 ± 14 ± 114.88
      P < .01 for difference between mothers enrolled or not in WIC.
      Food responsiveness3 ± 13 ± 11.60
      Satiety responsiveness2 ± 13 ± 117.16
      P < .01 for difference between mothers enrolled or not in WIC.
      Slowness in eating2 ± 13 ± 116.19
      P < .01 for difference between mothers enrolled or not in WIC.
      General appetite3 ± 14 ± 13.01
      Maternal/familial characteristics
       Age, y27 ± 632 ± 413.05
      P < .01 for difference between mothers enrolled or not in WIC.
       Body mass index, kg/m231 ± 627 ± 76.53
      P < .05
       Parity, primiparous (%)37 (17)72 (21)8.95
      P < .01 for difference between mothers enrolled or not in WIC.
       Annual family income level54.57
      P < .01 for difference between mothers enrolled or not in WIC.
      <$15,00041 (19)0 (0)
      $15,000 to $34,99935 (16)3 (1)
      $35,000 to $74,99917 (8)10 (3)
      ≥$75,0000 (0)72 (21)
      Not reported7 (3)14 (4)
       Level of education42.23
      P < .01 for difference between mothers enrolled or not in WIC.
      Did not complete high school12 (5)0 (0)
      High school degree39 (18)0 (0)
      Some college35 (16)14 (4)
      Bachelors or graduate degree11 (5)86 (25)
      Not reported4 (2)0 (0)
       Racial/ethnic category32.00
      P < .01 for difference between mothers enrolled or not in WIC.
      Non-Hispanic white26 (12)76 (22)
      Non-Hispanic black61 (28)3 (1)
      Hispanic white2 (1)14 (4)
      Hispanic black7 (3)0 (0)
      Asian/Pacific Islander2 (1)7 (2)
      Native American2 (1)0 (0)
       Feeding styles subscales
      From the Infant Feeding Style Questionnaire31 (possible score range: 1–5)
      Laissez-faire2 ± 13 ± 12.40
      Pressuring2 ± 12 ± 10.39
      Restrictive4 ± 13 ± 119.92
      P < .01 for difference between mothers enrolled or not in WIC.
      Responsive4 ± 15 ± 010.79
      P < .01 for difference between mothers enrolled or not in WIC.
      Feeding characteristics
       Milk type36.88
      P < .01 for difference between mothers enrolled or not in WIC.
      Exclusively breast milk9 (4)72 (21)
      Exclusively formula76 (35)10 (3)
      Mix of breast milk and formula15 (7)17 (5)
       Feed mode35.62
      P < .01 for difference between mothers enrolled or not in WIC.
      Exclusively breastfed2 (1)14 (4)
      Exclusively bottle fed89 (41)21 (6)
      Mix of breast and bottle9 (4)66 (19)
      WIC indicates the Special Supplemental Nutrition Program for Woman, Infants, and Children.
      Note: Values are presented as % (n) or mean ± SD and compared using chi-square tests of independence.
      a Data are from mothers enrolled or not in WIC (n = 75) with infants aged ≤6 mo who participated in infant feeding studies
      b From the Infant Behavior Questionnaire–Revised Very Short Form
      • Putnam S.P.
      • Helbig A.L.
      • Gartstein M.A.
      • Rothbart M.K.
      • Leerkes E.
      Development and assessment of short and very short forms of the infant behavior questionnaire-revised.
      (possible score range: 1–7)
      c From the Baby Eating Behavior Questionnaire
      • Llewellyn C.H.
      • van Jaarsveld C.H.
      • Johnson L.
      • Carnell S.
      • Wardle J.
      Development and factor structure of the Baby Eating Behaviour Questionnaire in the Gemini birth cohort.
      (possible score range: 1–5)
      d From the Infant Feeding Style Questionnaire
      • Thompson A.L.
      • Mendez M.A.
      • Borja J.B.
      • Adair L.S.
      • Zimmer C.R.
      • Bentley M.E.
      Development and validation of the Infant Feeding Style Questionnaire.
      (possible score range: 1–5)
      P < .05
      ∗∗ P < .01 for difference between mothers enrolled or not in WIC.

      Prevalence of Maternal Distraction During Feeding

      Table 2 presents results of the thematic analysis of mothers' feeding records. Mothers reported a variety of additional activities while feeding their infants, which were further categorized into technological vs non-technological distractions. Distractions were reported during 43% of feedings, with mothers reporting technological distractions during 26% of feedings and non-technological distractions during 17% of feedings. For the remaining 57% of feedings, mothers reported interacting with their infants or that they did not do anything else during the feeding, or they left the question blank. Reported feeding durations were not associated with reports of any type of distraction (F1,2784 = 0.19; P = .66) or technological distraction (F1,2784 = 0.05; P = .82) during feeding.
      Table 2Proportions of Feedings in Which Mothers Reported Distractions Vs No Distractions
      Data are from mothers enrolled or not in the Special Supplemental Nutrition Program for Woman, Infants, and Children (n = 75) with infants aged ≤6 mo who participated in infant feeding studies; these analyses were based on 2,982 recorded feedings.
      Themes%n
      Technological distraction reported26775
       Watching television20580
       Using a smartphone or tablet5161
       Using a computer126
       Multiple technologies08
      Non-technological distraction reported17504
       Talking on phone or to another adult4122
       Sleeping4120
       Reading newspaper, book, or magazine391
       Listening to music260
       Doing housework/caring for other children252
       Eating136
       Traveling123
      No distractions reported571,703
       Nothing specified521,544
       Interacting with baby5159
      a Data are from mothers enrolled or not in the Special Supplemental Nutrition Program for Woman, Infants, and Children (n = 75) with infants aged ≤6 mo who participated in infant feeding studies; these analyses were based on 2,982 recorded feedings.
      Of the 2,982 reported feedings, 36% (n = 1,075) were BFs (ie, from the breast) and 64% were bottle feedings (n = 1,906; note that feeding mode was not reported for 1 feeding). Of bottle feedings, 72% (n = 1,367) were formula, 26% (n = 500) were expressed breast milk, and 2% (n = 39) were a combination of breast milk and formula. Table 3 presents the percentages and odds of mothers' reports of any, technological, or no distractions as a function of feeding mode (BF vs bottle feeding) during the recorded feeding. Overall, mothers had similar odds of reporting any distraction (P = .68), technological distractions (P = .37), non-technological distractions (P = .67), or no distractions (P = .68) during BFs vs bottle feedings.
      Table 3Odds of Reporting Technological Distractions, Non-technological Distractions, or No Distractions During BFs Vs Bottle Feedings
      Data are from mothers enrolled or not in WIC (n = 75) with infants aged ≤6 mo who participated in infant feeding studies; these analyses were based on 2,982 recorded feedings
      ThemesBFsBottle FeedingsP
      %n%nOdds Ratio (95% Confidence Interval)
      For the logistic regression with estimation via generalized estimating equations model exploring whether feeding mode predicted the probability of mothers' reports of each activity, BF was specified as the referent group
      WIC participation did not moderate effects of feeding mode on the probability of mothers' reports of each activity.
      Technological distraction reported23249285260.79 (0.48–1.32).37
       Watching television1111525465
       Using smartphone or tablet10111350
       Using computer216110
       Multiple technologies1701
      Non-technological distraction reported18193163111.12 (0.66–1.92).67
       Sleeping444476
       Talking on phone or to another adult335587
       Reading newspaper, book, or magazine659232
       Listening to music331229
       Doing housework/caring for other children03349
       Eating217119
       Traveling04119
      No distractions reported59633561,0701.12 (0.65–1.93).68
       Nothing specified5356451980
       Interacting with baby669590
      BF indicates breastfeeding; WIC, Special Supplemental Nutrition Program for Woman, Infants, and Children.
      a Data are from mothers enrolled or not in WIC (n = 75) with infants aged ≤6 mo who participated in infant feeding studies; these analyses were based on 2,982 recorded feedings
      b For the logistic regression with estimation via generalized estimating equations model exploring whether feeding mode predicted the probability of mothers' reports of each activity, BF was specified as the referent group
      c WIC participation did not moderate effects of feeding mode on the probability of mothers' reports of each activity.

      Mothers' Intensities of Distracted Feeding

      When analyzed at the level of the individual, 92% of mothers reported a distraction during at least 1 feeding. A total of 83% of mothers reported a technological distraction during ≥1 feedings. Mothers' reports of distractions ranged from 0% to 100% of recorded feedings (mean = 43.9%; SD = 29.5%); similarly, reports of technological distractions ranged from 0% to 97% of recorded feedings (mean = 27.7%; SD = 24.0%).

      Associations Between Mothers' Intensities of Distracted Feeding and Infant and Mother Characteristics

      Table 4 illustrates the best-fit models for predicting mothers' intensities of any distraction and technological distractions. Significant predictors of mothers' intensities of any distraction during feeding were multiparity and mothers' perception of greater infant appetite. Significant predictors of mothers' intensities of technological distraction during feeding were mothers' racial/ethnic minority (eg, black, Hispanic, or Asian) status, adherence to a more laissez-faire feeding style, younger infant age, and perception of lower infant food responsiveness and greater infant appetite. Feeding mode; whether the mother was enrolled in WIC, education, and BMI; and infant sex, weight status, and temperament were not significant predictors of distraction in either model.
      Table 4Associations Between Characteristics of Mothers and Infants and Mothers' Intensities of Any Distraction and Technological Distraction During Feeding
      Data are from mothers enrolled or not in WIC (n = 75) with infants aged ≤6 mo who participated in infant feeding studies
      ModelDependent VariableIndependent VariablesCoefficient
      For multiple stepwise regression models exploring the combination of maternal (ie, feeding mode, education, race/ethnicity, parity, WIC status, body mass index, feeding styles) and infant (ie, sex, age, weight status, temperament, eating behaviors) characteristics that predicted maternal intensity of any or technological distraction
      SEP
      1Intensity of any distraction
      Calculated for each mother as: (number of feedings in which any distraction was reported)/(total number of feedings reported) × 100
      Multiparous (vs primiparous)18.277.43.02
      (F6.38; P = .003; R2 = 0.20)Infant appetite10.913.47.003
      2Intensity of technological distraction
      Calculated for each mother as: (number of feedings in which a technological distraction was reported)/(total number of feedings reported) × 100.
      White (vs black, Hispanic, or other)−13.564.93.008
      (F9.10; P < .001; R2 = 0.48)Mother laissez-faire feeding style6.832.75.02
      Infant age−0.830.35.02
      Infant food responsiveness−13.663.62< .001
      Infant appetite11.372.64< .001
      R2 indicates multivariate coefficient; WIC, the Special Supplemental Nutrition Program for Woman, Infants, and Children.
      a Data are from mothers enrolled or not in WIC (n = 75) with infants aged ≤6 mo who participated in infant feeding studies
      b For multiple stepwise regression models exploring the combination of maternal (ie, feeding mode, education, race/ethnicity, parity, WIC status, body mass index, feeding styles) and infant (ie, sex, age, weight status, temperament, eating behaviors) characteristics that predicted maternal intensity of any or technological distraction
      c Calculated for each mother as: (number of feedings in which any distraction was reported)/(total number of feedings reported) × 100
      d Calculated for each mother as: (number of feedings in which a technological distraction was reported)/(total number of feedings reported) × 100.

      Discussion

      The current study aimed to describe 1 potential barrier to responsive feeding that is particularly relevant in today's technology-focused society: the presence of and engagement with distractions during infant feeding. Findings from the study illustrated that distracted feeding is a common practice for both mothers who were and were not enrolled in WIC, regardless of mode of feeding. Although few studies described the extent to which caregivers engaged in distractions during feeding and other caregiver–child interactions, the findings of the current study were consistent with previous studies focused on bottle-feeding dyads
      • Golen R.P.
      • Ventura A.K.
      What are mothers doing while bottle-feeding their infants? Exploring the prevalence of maternal distraction during bottle-feeding interactions.
      and families with older children,
      • Radesky J.
      • Miller A.L.
      • Rosenblum K.L.
      • Appugliese D.
      • Kaciroti N.
      • Lumeng J.C.
      Maternal mobile device use during a structured parent-child interaction task.
      • Radesky J.S.
      • Kistin C.J.
      • Zuckerman B.
      • et al.
      Patterns of mobile device use by caregivers and children during meals in fast food restaurants.
      illustrating that significant proportions of caregivers frequently engaged with technological and other environmental stimuli during child feeding and mealtime interactions.
      The significance of caregiver responsiveness during feeding interactions is underlined by the belief that infants have an innate capacity to self-regulate
      • Dewey K.G.
      • Lonnerdal B.
      Infant self-regulation of breast milk intake.
      • Fomon S.J.
      • Filer Jr., L.J.
      • Thomas L.N.
      • Anderson T.A.
      • Nelson S.E.
      Influence of formula concentration on caloric intake and growth of normal infants.
      that develops during the first few months postpartum and that this development is shaped by interactional learning that occurs when the caregiver responds contingently and appropriately to infant cues.
      • DiSantis K.I.
      • Hodges E.A.
      • Johnson S.L.
      • Fisher J.O.
      The role of responsive feeding in overweight during infancy and toddlerhood: a systematic review.
      During early infancy, feeding interactions comprise a significant proportion of caregiver–infant interactions; thus, high-quality, synchronous feeding interactions provide the infant with both nutritive and socioemotional benefits.
      • Bowlby J.
      The making and breaking of affectional bonds. I. Aetiology and psychopathology in the light of attachment theory: an expanded version of the Fiftieth Maudsley Lecture, delivered before the Royal College of Psychiatrists, 19 November 1976.
      • Bowlby J.
      Attachment theory and its therapeutic implications.
      • Bowlby J.
      The making and breaking of affectional bonds. II. Some principles of psychotherapy: the fiftieth Maudsley Lecture.
      • Black M.M.
      • Aboud F.E.
      Responsive feeding is embedded in a theoretical framework of responsive parenting.
      • Engle P.L.
      • Pelto G.H.
      Responsive feeding: implications for policy and program implementation.
      • Hurley K.M.
      • Cross M.B.
      • Hughes S.O.
      A systematic review of responsive feeding and child obesity in high-income countries.
      In light of this understanding, an important question is whether the presence of certain distractions during feeding interactions affect the responsiveness of caregivers to children's cues and needs.
      The current study tested several hypotheses aimed at understanding whether certain dyads may be more prone to distracted feeding than others. Inconsistent with previous research,
      • Golen R.P.
      • Ventura A.K.
      What are mothers doing while bottle-feeding their infants? Exploring the prevalence of maternal distraction during bottle-feeding interactions.
      • Wright P.
      • Fawcett J.
      • Crow R.
      The development of differences in the feeding behaviour of bottle and breast fed human infants from birth to two months.
      • Crow R.A.
      • Fawcett J.N.
      • Wright P.
      Maternal behavior during breast- and bottle-feeding.
      hypothesized associations were not found between distracted feeding and BF, mothers' age and self-reported tendencies toward responsive feeding, and infants' temperamental characteristics. However, the current study supported hypothesized associations between distracted feeding and parity and infant eating behaviors. Interpretation of these findings within the broader context of previous research on caregiver feeding practices and styles reveals a number of consistencies. Previous research similarly found that multiparous mothers reported greater levels of distraction during infant feeding,
      • Golen R.P.
      • Ventura A.K.
      What are mothers doing while bottle-feeding their infants? Exploring the prevalence of maternal distraction during bottle-feeding interactions.
      which makes intuitive sense given the increased number of children for whom these mothers cared. Although further research is needed to verify whether distracted feeding is a facet of non-responsive feeding, the finding that minority race/ethnicity was a significant predictor of technological distraction is consistent with previous research illustrating that racial/ethnic minorities were more likely to report using practices characterized by low responsiveness to child cues.
      • Gross R.S.
      • Mendelsohn A.L.
      • Fierman A.H.
      • Hauser N.R.
      • Messito M.J.
      Maternal infant feeding behaviors and disparities in early child obesity.
      • Skala K.
      • Chuang R.J.
      • Evans A.
      • Hedberg A.M.
      • Dave J.
      • Sharma S.
      Ethnic differences in the home food environment and parental food practices among families of low-income Hispanic and African-American preschoolers.
      In addition, the association between higher levels of technological distraction and adherence to a laissez-faire feeding style makes intuitive sense because a laissez-faire feeding style is characterized by feeding practices low in involvement and structure (eg, propping the bottle, watching TV during feeding).
      • Thompson A.L.
      • Mendez M.A.
      • Borja J.B.
      • Adair L.S.
      • Zimmer C.R.
      • Bentley M.E.
      Development and validation of the Infant Feeding Style Questionnaire.
      Taken together, these findings suggest that a number of factors, such as family structure, cultural beliefs, and broader feeding practices and styles, influence mothers’ tendencies toward distracted feeding and abilities to engage in responsive feeding.
      However, the limitations of the current study underline possible caveats to this interpretation. First, the correlational and self-report nature of this study precludes abilities to determine cause and effect relationships. For example, because infant eating behaviors (eg, appetite, food responsiveness) were reported by mothers, it is unclear whether maternal distraction influences the development of infants' appetite and food responsiveness or whether mothers who perceive their infants to have larger appetites and lower food responsiveness attend to distractions during the feeding for other reasons (eg, they feel the feeding takes too long). Second, the main variable of interest was assessed through an open-ended question on an infant feeding diary. A strength of this approach is that it provided rich qualitative data on the wide array of things mothers do while feeding their infants. However, it is also possible that mothers underreported their levels of distraction because self-reported engagement in some distractors tends to be biased, such as mobile devices, which are used in short bouts, interspersed through the day.
      • Berolo S.
      • Steenstra I.
      • Amick 3rd, B.C.
      • Wells R.P.
      A comparison of two methods to assess the usage of mobile hand-held communication devices.
      In a related manner, interpretation of this thematic analysis of maternal reports is also limited by the fact that when a mother left a section blank, it was not known whether this was because no distractions were present or whether the mother failed to report. Mothers were not provided instruction regarding when to complete the records (eg, in real time vs at the end of the day); for those who completed records during the feeding, the records may actually have introduced an additional source of distraction. Finally, although associations between feeding mode and distraction were explored, only 5 participants were exclusively BF and 23 were BF and bottle feeding; thus, although a substantial number of BFs were recorded, these feedings came from a limited number of participants, which limits the generalizability of the findings.

      Implications for Research and Practice

      An important focus for future research is to determine what impact, if any, distracted feeding has on the quality and outcome of the feeding interaction in the short term and on infants' developing eating behaviors and self-regulatory abilities in the long term. In addition, given evidence for interindividual variability in mothers' level of responsiveness during feeding interactions,
      • Bowlby J.
      The making and breaking of affectional bonds. I. Aetiology and psychopathology in the light of attachment theory: an expanded version of the Fiftieth Maudsley Lecture, delivered before the Royal College of Psychiatrists, 19 November 1976.
      • Hurley K.M.
      • Cross M.B.
      • Hughes S.O.
      A systematic review of responsive feeding and child obesity in high-income countries.
      • Hodges E.A.
      • Johnson S.L.
      • Hughes S.O.
      • Hopkinson J.M.
      • Butte N.F.
      • Fisher J.O.
      Development of the responsiveness to child feeding cues scale.
      • Brown A.
      • Arnott B.
      Breastfeeding duration and early parenting behaviour: the importance of an infant-led, responsive style.
      • Fildes A.
      • van Jaarsveld C.H.
      • Llewellyn C.
      • Wardle J.
      • Fisher A.
      Parental control over feeding in infancy: influence of infant weight, appetite and feeding method.
      • Jansen E.
      • Mallan K.M.
      • Byrne R.
      • Daniels L.A.
      • Nicholson J.M.
      Breastfeeding duration and authoritative feeding practices in first-time mothers.
      future research should explore whether certain psychosocial factors, such as responsive feeding skills, postpartum depression, participation in WIC or other federal assistance programs, or cultural beliefs, moderate the potential impact of distractors on feeding outcomes. This research would elucidate whether distracted feeding is a form of non-responsive feeding or whether some mothers are still able to feed responsively even in the presence of technological or other distractions.
      Further research using experimental designs and/or observational measures of maternal and infant behavior in the presence of environmental distractors is needed to understand better the extent to which mothers attended to distractors vs their infant during feeding and the extent to which the presence of distractors affects feeding interactions. If future research suggests that maternal distraction decreases the quality of the feeding interaction, targeted efforts within both research and practice should focus on educating mothers and other caregivers about the potential effects of caregiver distraction on infant feeding and developmental outcomes. Efforts to develop and evaluate approaches to help caregivers better understand and attend to their infants' cues, especially in the presence of technological and other distractors, may also be warranted.

      Acknowledgments

      This project described was supported by a Simms/Mann Institute Faculty Fellowship, the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health under Award No. R03HD080730, and a Drexel College of Nursing and Health Professions research grant. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors thank the mothers and infants who participated in this study.

      Conflict of Interest

      The authors have not stated any conflicts of interest.

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