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Not only do caregivers play a prominent role in what and when children are fed, they also determine how children are fed. Parental feeding styles play a significant role in establishing healthy behaviors for optimal growth and development [38]. The WHO recommends that parents and caregivers practice RF [14]. According to Black and Aboud RF, includes “(1) ensuring that the feeding context is pleasant with few distractions; (2) encouraging and attending to the child’s signals of hunger and satiety; and (3) responding to the child in a prompt, emotionally supportive, contingent, and developmentally appropriate manner” [15]. Non-RF is defined as “A lack of reciprocity between the parent and child, with the caregiver taking excessive control of the feeding situation (pressuring or restricting food intake), the child completely controlling the feeding situation (indulgent), or the caregiver being uninvolved during meals (laissez faire)” [39]. The importance of the dyadic relationship and the role of infant temperament play a role in how caregiver feeding style may be influenced. For example, caregivers who perceive infants to be “fussy” or “active” may introduce complementary foods more often, as a way to sooth a crying or an active infant [40, 41]. Research on feeding styles and its association with breastfeeding and growth outcomes has been conducted in high-, middle-, and low-income countries [42-44]. Although researchers recognize the importance of RF, there are limited data to assess how RF messages combined with improved CF behaviors contribute to child diet or growth.

An observational study of 100 meal time observations of children aged 12–23 months in rural Ethiopia reported that caregivers of stunted children had poorer IYCF practices, such as being less responsive to the child’s hunger and satiation cues, compared to caregivers of non-stunted children [45]. A randomized controlled behavioral intervention trial in rural Andhra Pradesh, India, conducted a 3-arm study among 600 mother-child pairs within 60 rural villages. The first arm was the control/standard of care, the second arm received an IYCN feeding intervention, and the third arm received the IYCN intervention with additional messages and skills on RF and child development. Although the intervention did not show better growth within the third arm (but did in the second arm), mental development scores in the RF group were significantly higher compared to the control and CF groups [46]. In a cohort study of 217 African-American mother-infant pairs in North Carolina, caregiver feeding style data were collected from 3 to 18 months of infant age using the Infant Feeding Style Questionnaire [47]. Parental feeding styles, including beliefs and practices, had a significant impact on both infant diet and growth, with pressuring and indulgent feeding styles associated with negative IYCF behaviors, such as greater infant energy intake, reduced odds of breastfeeding, and higher levels of age-inappropriate feeding of liquids and solids [48]. In the same study, Slining et al. [49] found that both infant overweight and high subcutaneous fat were associated with delayed infant motor development.