Parental feeding attitudes and their associations with children’s eating behaviors and nutritional intake in a clinical sample with feeding difficulties: a cross-sectional study

Introduction

Proper nutrition during early childhood is essential for optimal growth, cognitive development, and long-term health outcomes. However, establishing healthy eating habits in young children is often challenging due to picky eating behaviors, food refusal, and mealtime struggles, which can lead to inadequate nutrient intake and growth concerns (1-3). Research suggests that parental feeding attitudes and practices play a pivotal role in shaping children’s dietary habits, as caregivers are responsible for food choices, meal structure, and the social environment surrounding eating (4,5). While responsive feeding approaches, such as structured mealtimes and positive reinforcement, are associated with healthier eating behaviors, coercive or anxiety-driven feeding practices may exacerbate mealtime difficulties and reinforce problematic eating patterns.

The relationship between parental feeding attitudes and children’s eating behaviors is complex and bidirectional. On the one hand, caregivers’ concerns about food intake may lead to pressuring, bribing, or restricting food choices, which can heighten children’s food neophobia and selective eating tendencies (6). On the other hand, children’s resistance to eating or prolonged meal durations can increase parental stress, leading to frustration and inconsistent feeding approaches (7). Previous studies have indicated that coercive feeding strategies may result in negative mealtime interactions, food aversions, and inadequate dietary intake, yet few studies have systematically examined the interplay between feeding attitudes, children’s eating behaviors, and nutritional outcomes in a comprehensive manner (8,9).

This study aims to explore the associations between parental feeding attitudes, children’s eating behaviors, and macronutrient intake in young children. By analyzing the extent to which caregiver concerns, emotional responses, and feeding strategies correlate with child dietary patterns, this study seeks to provide insights into the potential consequences of different feeding approaches on children’s nutrition. The findings will help inform evidence-based recommendations for parents and healthcare providers to promote supportive, structured, and non-coercive feeding practices that foster healthy eating habits in early childhood. We present this article in accordance with the STROBE reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-1-885/rc).

Methods

Study design and participants

This study utilized a cross-sectional design to investigate the relationships between parental feeding attitudes, children’s eating behaviors, and nutritional intake. Participants were recruited from April 2022 to December 2024 at the Children’s Health Clinic, with a total of 516 children and their primary caregivers included in the final analysis. The inclusion criteria required that children be between 6 months and 5 years old, have complete anthropometric and dietary data, and have caregivers who were primarily responsible for their daily feeding practices. There were no restrictions on the type of pediatric patients included; however, all participants visited the pediatric outpatient clinic due to feeding-related concerns, such as picky eating, poor appetite, prolonged mealtimes, or nutritional deficiencies. This study specifically focused on feeding difficulties and related parental concerns, which were the primary reasons for seeking pediatric consultation.

Data collection

Data collection involved structured questionnaires and anthropometric measurements. Caregivers completed the Child Eating Behaviors and Parental Feeding Attitudes Questionnaire, a 30-item instrument adapted from established validated tools, primarily the Children’s Eating Behaviour Questionnaire (CEBQ) (10) and the Caregiver’s Feeding Styles Questionnaire (CFSQ) (11), with modifications to enhance cultural relevance (e.g., phrasing aligned with common Chinese feeding practices) and suitability for a clinical population presenting with feeding difficulties. The questionnaire was not developed de novo but tailored based on these parent instruments and pilot-tested in our clinical setting for comprehension and applicability. It assesses children’s eating behaviors (items 1–13) and caregivers’ feeding attitudes and practices (items 14–30). Items are rated on a 5-point Likert scale ranging from 1 (always) to 5 (never), with uniform directionality across all items (no reverse-coding required): higher scores on child eating behavior items indicate fewer problematic behaviors, whereas higher scores on parental items generally reflect lower anxiety, less coercive or negative practices, and more positive/supportive attitudes. Internal consistency reliability in the current sample was acceptable to good, with Cronbach’s α=0.81 for the child eating behaviors section (13 items) and Cronbach’s α=0.75 for the parental feeding attitudes and practices section (17 items). Construct validity is supported by the expected pattern of inter-item and inter-section correlations observed in this study (e.g., parental anxiety items positively correlated with child problematic eating behaviors such as selective eating and prolonged meals), which align with theoretical frameworks from the parent instruments and prior literature on feeding dynamics.

Dietary intake data were collected using a caregiver-completed semi-quantitative food frequency questionnaire (FFQ) designed to capture the child’s habitual intake of key food groups and macronutrients over a typical month (referencing usual frequency and standard portion sizes). The FFQ included commonly consumed foods in the Chinese pediatric population and asked caregivers to report average consumption frequency (e.g., daily, weekly) and typical portion sizes (guided by visual aids and age-appropriate standards). This approach inherently accounts for variation across weekdays and weekends through recall of habitual patterns, without requiring prospective recording. Macronutrient intake (energy in kcal, protein, fat, and carbohydrates in g) was calculated based on standard Chinese food composition databases. Absolute intakes (rather than percentages of recommendations) were used for correlation analyses with feeding variables. The FFQ was selected for its practicality in assessing long-term usual intake in a large outpatient sample, avoiding the burden of multi-day records. Macronutrient intake, including energy (kcal), protein (g), fat (g), and carbohydrates (g), was analyzed in relation to feeding behaviors and parental attitudes.

Statistical analysis

All statistical analyses were conducted using Python (pandas, scipy, seaborn, matplotlib). Descriptive statistics [mean, standard deviation (SD), and percentage distributions] were calculated for demographic characteristics, eating behaviors, parental feeding attitudes, and dietary intake.

Spearman rank correlation analysis was performed to examine the relationships between parental feeding attitudes, children’s eating behaviors, and nutritional intake. Correlation coefficients (rho) were used to determine the strength of associations, with significance levels set at P<0.05. Heatmaps were generated to visually illustrate key relationships between feeding practices and dietary outcomes.

Boxplots were used to compare macronutrient intake distributions, while frequency distributions were analyzed for common feeding behaviors and parental concerns.

Ethical considerations

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethical Committee of Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Children and Adolescents’ Health and Diseases (No. 2022-IRB-253). Written informed consent was obtained from all participating caregivers before data collection.

Results

Participant characteristics

A total of 516 participants were included in the study, consisting of both male and female children. The mean age of participants was approximately 25.9 months (SD =15.05 months), with a range from 5.6 to 60 months. The average height was 83.5 cm (SD =10.99 cm), and the mean weight was 10.47 kg (SD =2.93 kg).

To assess growth and nutritional status, Z-scores for height-for-age, weight-for-age, and body mass index (BMI)-for-age were calculated. On average, children had a height-for-age Z-score of −1.03, indicating mild stunting tendencies in some participants. The weight-for-age Z-score was −1.23, and the BMI-for-age Z-score was −0.87, suggesting slight underweight trends in the sample (Table 1).

Children’s eating behaviors

The analysis of children’s eating behaviors reveals diverse patterns in mealtime habits, food preferences, and feeding challenges. A considerable number of children do not consistently eat together with adults, as reflected in the mean score of 2.91 (SD =1.37) for eating alone. Distractions such as toys, television, or mobile phones are commonly used during meals, with an average score of 2.77 (SD =1.43), indicating that external stimuli are often necessary to encourage eating. Additionally, some children exhibit low interest in food, with a mean score of 2.55 (SD =1.17), often refusing to open their mouths or pushing food away.

Nausea or vomiting in response to disliked foods is also observed among participants, with a mean score of 3.11 (SD =1.34), suggesting that food aversion is a notable issue. Prolonged meal durations, exceeding 30 minutes, are relatively frequent, as indicated by a mean score of 3.04 (SD =1.45). Moreover, irregular eating patterns are prevalent, with an average score of 3.61 (SD =1.11), reflecting inconsistencies in mealtime structure. Selective eating is another common concern, with some children strongly preferring only one or two specific foods, yielding a mean score of 3.06 (SD =1.42). Furthermore, many children prefer soft or pureed foods over solid textures, as evidenced by a mean score of 3.83 (SD =1.22), highlighting potential delays in the acceptance of more complex food consistencies (Table 2).

Parental feeding attitudes and practices

The analysis of parental feeding attitudes and practices highlights diverse emotional responses, feeding strategies, and household dynamics related to children’s eating habits. Parents’ concern over whether their children eat too much or too little was notably high, with a mean score of 2.00 (SD =1.04), indicating that feeding-related anxiety is common. Parental frustration regarding children’s eating behaviors averaged 2.32 (SD =1.18), suggesting that some caregivers experience emotional distress when managing their child’s diet. Similarly, anxiety when a child refuses to eat was reflected in a mean score of 2.42 (SD =1.12), underscoring the psychological strain associated with feeding challenges.

Parental use of coercion, such as threats or bribes to encourage eating, was relatively moderate, with an average score of 3.35 (SD =1.34). Family-wide attention to eating habits was high, with a mean score of 1.77 (SD =0.84), demonstrating that caregivers place significant emphasis on children’s nutrition. However, negative feeding interactions, such as parental anger or complaints about their child’s eating habits, were reported with a mean score of 2.93 (SD =1.30), reflecting the stress that mealtime conflicts may introduce.

Parental feeding approaches varied widely, with some caregivers showing a lack of persistence in encouraging eating (mean =3.51, SD =1.16), while others were more willing to offer alternative foods (mean =2.55, SD =0.99) if their child refused a particular meal. The belief that eating is an innate skill that does not require teaching was fairly high (mean =4.10, SD =1.17), as was the tendency to place less emphasis on structuring mealtime behaviors (mean =3.76, SD =1.30). Additionally, some parents adopted unstructured feeding approaches, such as allowing children to eat whenever they wanted, leading to a mean score of 3.82 (SD =1.23).

Regarding extreme feeding practices, the use of physical force to make a child eat was relatively uncommon, with a mean score of 4.64 (SD =0.82), suggesting that most parents avoid coercive feeding tactics. However, family disagreements on feeding practices (mean =3.34, SD =1.20) and visible conflicts during meals (mean =3.89, SD =1.09) indicate that household tension surrounding mealtimes is not uncommon. Parental confidence in child-rearing (mean =3.18, SD =1.05) was moderate, while parental exhaustion related to feeding struggles was also reported (mean =2.85, SD =1.12). Lastly, family support and encouragement varied, with an average score of 2.55 (SD =1.12), suggesting differences in external assistance available to caregivers (Table 3).

Nutritional intake analysis

The assessment of children’s nutritional intake reveals variations in macronutrient consumption, providing insights into dietary adequacy and imbalances. The average energy intake among participants was 761.4 kcal (SD =219.3 kcal), indicating differences in caloric consumption across the sample. Protein intake averaged 28.3 g (SD =9.5 g), with protein accounting for approximately 117.5% of the recommended intake, suggesting that many children may be consuming adequate or even excessive protein relative to their needs. Fat intake was measured at an average of 29.7 g (SD =8.9 g), contributing to about 81.2% of the recommended fat intake, while carbohydrate consumption averaged 102.3 g (SD =29.7 g), making up approximately 87.4% of the recommended intake.

Despite the general adequacy of macronutrient intake, the variability across participants suggests that some children may experience imbalances in nutrient distribution. A visual representation using boxplots illustrates the spread of macronutrient intake levels, highlighting outliers and variability in energy, protein, fat, and carbohydrate consumption (Figure 1).

Figure 1 Distribution of macronutrient intake among participants. This boxplot illustrates the distribution of energy, protein, fat, and carbohydrate intake among the study participants. The spread of the data highlights individual variations in macronutrient consumption, with some children falling below or exceeding recommended intake levels.

Associations between feeding attitudes, eating behaviors, and nutritional status

Spearman rank correlation analysis revealed several significant associations between parental feeding attitudes, children’s eating behaviors, and nutritional intake in this clinical sample of young children with feeding difficulties. As summarized in Table 4, moderate-strength associations (|rho| ≥0.30) were observed between higher parental concern about intake and greater child selective eating (rho =0.39, P<0.001), parental anxiety during refusal and child food disinterest (rho =0.35, P<0.001), parental frustration and prolonged meal durations (rho =0.32, P<0.001), and coercive strategies (e.g., threats or bribes) and food refusal/nausea aversions (rho =0.30, P<0.001). These patterns highlight potential bidirectional dynamics, where caregiver emotional responses and child problematic behaviors may mutually influence each other.

Smaller but notable associations linked supportive or low-coercion attitudes (e.g., higher confidence and structured routines) with higher protein (rho =0.26, P<0.05) and carbohydrate intake (rho =0.25, P<0.05), as well as irregular child eating patterns with lower energy intake (rho =−0.24, P<0.01). Overall, these exploratory associations suggest that less anxious and non-coercive parental approaches are linked to fewer mealtime challenges and slightly better macronutrient intake, though interpretations remain descriptive given the cross-sectional design.

Significant correlations between parental attitudes and child eating behaviors

Further analysis focused on associations between parental feeding attitudes and child eating behaviors, with the most clinically relevant moderate-strength patterns summarized in Table 5. The strongest association was between parental concern about intake and child selective eating (rho =0.39, P<0.001), followed by parental anxiety during refusal and child food disinterest/refusal (rho =0.35, P<0.001), parental frustration and prolonged meal durations (rho =0.32, P<0.001), and coercive strategies with nausea/gagging or refusal (rho =0.30, P<0.001). These moderate associations (|rho| ≥0.30) are consistent with bidirectional interplay in feeding difficulties, where heightened caregiver stress may coincide with more resistant child behaviors, and vice versa.

An inverse moderate association was noted between positive family support/encouragement and the need for distractions or poor mealtime structure (rho =−0.31, P<0.001), suggesting that supportive environments are linked to more positive eating habits. These findings underscore reciprocal parent-child dynamics in this clinical population and emphasize the potential value of addressing parental attitudes in feeding interventions.

Discussion

This study highlights the significant associations between parental feeding attitudes, children’s eating behaviors, and nutritional intake in a clinical sample of young children presenting with feeding difficulties, reinforcing the critical role that caregivers play in shaping dietary habits in this population. One of the most notable findings is the strong correlation between parental concern about food intake and selective eating behaviors. Parents who frequently worry about whether their child is eating enough tend to have children who limit their diet to only one or two preferred foods. This pattern is consistent with a bidirectional relationship where caregiver concerns and child food selectivity may mutually influence each other (12,13).

Furthermore, the study found that parental frustration and anxiety during feeding were associated with prolonged meal durations and irregular eating patterns. When caregivers experience stress or discouragement over their child’s eating habits, mealtimes tend to become longer and more difficult, likely due to repeated attempts to encourage food consumption or ongoing child resistance. This supports the idea that negative parental emotions contribute to mealtime struggles, potentially making feeding experiences more stressful for both the child and the caregiver (14). On the contrary, parental confidence in feeding and family support were linked to more structured and positive feeding behaviors, emphasizing the importance of creating a low-pressure, supportive mealtime environment to encourage healthy eating habits.

Another key finding is the negative impact of coercive feeding strategies, such as using threats or bribes to encourage eating. These practices were positively correlated with food refusal and nausea-related eating aversions, indicating that forceful feeding approaches may lead to increased child resistance and negative emotional responses toward food. This is consistent with studies suggesting that external pressure to eat often backfires, making children less likely to eat and enjoy food (15,16). Instead, responsive feeding approaches, where children are encouraged but not forced to eat, have been shown to promote better self-regulation and a healthier relationship with food.

In terms of nutritional outcomes, the study found that children with irregular eating patterns and prolonged mealtimes tended to have lower energy and fat intake, raising concerns about potential nutrient deficiencies. Conversely, structured parental feeding approaches, such as meal planning and consistent routines, were associated with improved protein and carbohydrate intake, suggesting that feeding structure plays a crucial role in ensuring adequate nutrition. These findings underscore the importance of educating caregivers on effective, child-centered feeding practices that promote balanced dietary intake while minimizing mealtime conflicts.

Despite its valuable insights, this study has several limitations that should be considered when interpreting the findings. First, the cross-sectional design prevents the establishment of causal relationships between parental feeding attitudes, children’s eating behaviors, and nutritional intake. Future longitudinal studies are needed to assess how these relationships evolve over time. Second, the study relied on self-reported data from caregivers, which may introduce recall bias or social desirability bias, as parents might overestimate or underestimate intake or report what they perceive as socially desirable. Although FFQ is a standard and validated approach for capturing habitual intake in young children and has been used extensively in similar pediatric nutrition studies, it is subject to recall error and may be less precise than prospective methods such as weighed food records or multiple-day diaries. This potential limitation should be considered when interpreting the macronutrient intake results. Additionally, the sample was recruited from pediatric outpatient clinics, where all children were seeking care specifically for feeding-related concerns (e.g., picky eating, poor appetite, prolonged mealtimes, or suspected nutritional deficiencies). This clinical recruitment strategy means the findings primarily reflect dynamics in families experiencing notable feeding challenges and may not generalize to the broader population of children with typical eating behaviors or without clinical feeding concerns. Future studies in community-based or general pediatric samples are needed to determine the extent to which these associations apply more widely. Another limitation is the lack of direct observational data, as all feeding behaviors were based on parental perceptions rather than direct assessments, which could have provided more objective insights into mealtime interactions. Finally, the study did not account for potential confounding factors such as socioeconomic status, cultural influences, or parental education levels, which may also impact feeding attitudes and child nutrition. The statistical approach relied on bivariate Spearman correlations without adjustment for multiple comparisons, increasing the risk of spurious associations in this exploratory analysis with numerous variables. Additionally, no multivariable regression models were employed to control for potential confounders such as child age, sex, or nutritional status (e.g., growth Z-scores), limiting the ability to isolate independent associations. These unadjusted bivariate findings should therefore be interpreted cautiously as descriptive patterns rather than confirmatory evidence. Future research could incorporate adjusted regression analyses or structural equation modeling to address confounding and strengthen causal inferences. Future research should consider these variables to provide a more comprehensive understanding of the factors shaping childhood feeding behaviors and dietary outcomes.

This study highlights the significant associations between parental feeding attitudes, children’s eating behaviors, and nutritional intake. These associations underscore the likely bidirectional nature of feeding interactions, where child eating behaviors can evoke parental emotional responses, and vice versa. Findings suggest that parental anxiety, coercive feeding strategies, and inconsistent mealtime structures are linked to food refusal, selective eating, and lower nutrient intake, whereas supportive and structured feeding approaches contribute to healthier eating behaviors. These results, based on exploratory bivariate associations in a clinical sample, was associated with the importance of non-coercive, child-centered feeding practices to promote balanced nutrition and positive mealtime interactions. Future research should explore longitudinal and intervention-based approaches to further understand the long-term impact of feeding dynamics and to develop evidence-based strategies for improving childhood nutrition.

Conclusions

In this clinical sample of young children with feeding difficulties, parental feeding attitudes were significantly associated with children’s problematic eating behaviors and, to a lesser extent, nutritional intake. Greater parental concern, anxiety, frustration, and coercive feeding practices were linked to more severe feeding problems, whereas more supportive feeding environments were associated with more positive mealtime patterns. These findings underscore the importance of incorporating parental factors into the assessment and management of pediatric feeding difficulties.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-1-885/rc

Data Sharing Statement: Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-1-885/dss

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-1-885/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-1-885/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethical Committee of Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Children and Adolescents’ Health and Diseases (No. 2022-IRB-253). Written informed consent was obtained from all participating caregivers before data collection.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Taylor CM, Emmett PM. Picky eating in children: causes and consequences. Proc Nutr Soc 2019;78:161-9. [Crossref] [PubMed]
2. Baraskewich J, von Ranson KM, McCrimmon A, et al. Feeding and eating problems in children and adolescents with autism: A scoping review. Autism 2021;25:1505-19. [Crossref] [PubMed]
3. Scaglioni S, De Cosmi V, Ciappolino V, et al. Factors Influencing Children's Eating Behaviours. Nutrients 2018;10:706. [Crossref] [PubMed]
4. Smith AD, Sanchez N, Reynolds C, et al. Associations of parental feeding practices and food reward responsiveness with adolescent stress-eating. Appetite 2020;152:104715. [Crossref] [PubMed]
5. Rylatt L, Cartwright T. Parental feeding behaviour and motivations regarding pre-school age children: A thematic synthesis of qualitative studies. Appetite 2016;99:285-97. [Crossref] [PubMed]
6. Greene E, Murrin C. Parental influences on children's dairy products consumption: a narrative review. Public Health Nutr 2023;26:976-93. [Crossref] [PubMed]
7. Scaglioni S, Salvioni M, Galimberti C. Influence of parental attitudes in the development of children eating behaviour. Br J Nutr 2008;99:S22-5. [Crossref] [PubMed]
8. Sdravou K, Andreoulakis E, Printza A, et al. Parental management of feeding problems in young children-a population-based study. Int J Pediatr Otorhinolaryngol 2020;136:110162. [Crossref] [PubMed]
9. Khalsa AS, Woo JG, Kharofa RY, et al. Parental intuitive eating behaviors and their association with infant feeding styles among low-income families. Eat Behav 2019;32:78-84. [Crossref] [PubMed]
10. Wardle J, Guthrie CA, Sanderson S, et al. Development of the Children's Eating Behaviour Questionnaire. J Child Psychol Psychiatry 2001;42:963-70. [Crossref] [PubMed]
11. Hughes SO, Power TG, Orlet Fisher J, et al. Revisiting a neglected construct: parenting styles in a child-feeding context. Appetite 2005;44:83-92. [Crossref] [PubMed]
12. Monge-Rojas R, Smith-Castro V, Colon-Ramos U, et al. Parental feeding styles and adolescents' healthy eating habits. Structure and correlates of a Costa Rican questionnaire. Appetite 2010;55:253-62. [Crossref] [PubMed]
13. Chapman L, Cartwright-Hatton S, Thomson A, et al. Parental eating disorders: A systematic review of parenting attitudes, behaviours, and parent-child interactions. Clin Psychol Rev 2021;88:102031. [Crossref] [PubMed]
14. Scaglioni S, Arrizza C, Vecchi F, et al. Determinants of children's eating behavior. Am J Clin Nutr 2011;94:2006S-11S. [Crossref] [PubMed]
15. Mahmood L, Flores-Barrantes P, Moreno LA, et al. The Influence of Parental Dietary Behaviors and Practices on Children's Eating Habits. Nutrients 2021;13:1138. [Crossref] [PubMed]
16. Yee AZ, Lwin MO, Ho SS. The influence of parental practices on child promotive and preventive food consumption behaviors: a systematic review and meta-analysis. Int J Behav Nutr Phys Act 2017;14:47. [Crossref] [PubMed]