Exclusive breastfeeding and parental styles in children with feeding difficulties

Abstract

To examine the prevalence of exclusive breastfeeding (EBF) and verify the associations between EBF and its duration with parental styles among children with feeding difficulties from a Brazilian reference center.
This was a cross-sectional study with children from a reference center in nutrition and feeding difficulties. Socio-demographics, parental styles, and breastfeeding duration were pulled down from questionnaires collected at the first clinical appointment. EBF was assessed using a single question and coded from never to ≥ 6 months duration. Parental styles were classified into four styles, as authoritarian, authoritative, indulgent, and uninvolved. Descriptive statistics and linear regressions were calculated and significant values established at < 0.05.
From 194 children that participated in this study, 19.23% were never breastfed, and 52.31% were exclusively breastfed for 6 months or more. Authoritative mothers (50.0%) had a higher prevalence for EBF for more than 6 months, while uninvolved mothers (33.33%) had a higher prevalence for never breastfeeding their children. Children who were longer EBF was positively associated with authoritative (ß = 2.15, 95% CI 0.62–3.68), authoritarian (ß = 1.92, 95% CI 0.37–3.47), and indulgent (ß = 2.20 95% CI 0.67–3.73) as compared to uninvolved parents.
About 19% of the children were never breastfed, and 52% were exclusively breastfed for at least 6 months. Breastfeeding can be influenced by parenting style. Therefore, specific guidelines may be necessary, aiming at the success of this very significant period for mother and child.

Full text

Vol.:(0123456789)
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Nutrire (2023) 48:50
https://doi.org/10.1186/s41110-023-00237-4
RESEARCH
Exclusive breastfeeding andparental styles inchildren withfeeding
difficulties
PriscilaMaximino1 · VictoriaFranco2· AndreaRomerodeAlmeida3· LuanaRomãoNogueira1,2 ·
MauroFisberg4
Received: 11 April 2023 / Accepted: 3 October 2023
© The Author(s), under exclusive licence to Springer Nature Switzerland AG 2023
Abstract
Purpose To examine the prevalence of exclusive breastfeeding (EBF) and verify the associations between EBF and its dura-
tion with parental styles among children with feeding difficulties from a Brazilian reference center.
Methods This was a cross-sectional study with children from a reference center in nutrition and feeding difficulties. Socio-
demographics, parental styles, and breastfeeding duration were pulled down from questionnaires collected at the first clinical
appointment. EBF was assessed using a single question and coded from never to ≥ 6months duration. Parental styles were
classified into four styles, as authoritarian, authoritative, indulgent, and uninvolved. Descriptive statistics and linear regres-
sions were calculated and significant values established at < 0.05.
Results From 194 children that participated in this study, 19.23% were never breastfed, and 52.31% were exclusively breast-
fed for 6months or more. Authoritative mothers (50.0%) had a higher prevalence for EBF for more than 6months, while
uninvolved mothers (33.33%) had a higher prevalence for never breastfeeding their children. Children who were longer EBF
was positively associated with authoritative (ß = 2.15, 95% CI 0.62–3.68), authoritarian (ß = 1.92, 95% CI 0.37–3.47), and
indulgent (ß = 2.20 95% CI 0.67–3.73) as compared to uninvolved parents.
Conclusion About 19% of the children were never breastfed, and 52% were exclusively breastfed for at least 6months.
Breastfeeding can be influenced by parenting style. Therefore, specific guidelines may be necessary, aiming at the success
of this very significant period for mother and child.
Keywords Parental styles· Exclusive breastfeeding· Feeding difficulties· Picky eating
Introduction
Feeding difficulties are characterized as a pattern of oral con-
sumption of energy and nutrients that differ from accepted
standards [1], and parents generally reported dissatisfaction
on their kids feeding patterns. The prevalence rate ranges
between 20 and 30% on children worldwide [1, 2] and in
Brazil, evidence from children with feeding difficulties var-
ies from 10 [3] to 36% [4]. These variations may be associ-
ated to the wide definition and measurements used in the
studies [5], given that the term feeding difficulties covers a
wide spectrum of problems.
Overall, the term “feeding difficulties” covers an umbrella
definition that are used to meet more severe problems that
ranges from total eating refusal to parents’ misinterpreta-
tions [2]. Feeding difficulties may include limiting, restrict-
ing, and/or avoiding certain foods for a range of purposes,
food selectivity, and limiting appetite [5]. These difficulties
have emerged as an important indicator of health in pre-
school age populations [6–8]. Strong evidence exists linking
feeding difficulties with breastfeeding [9], parental styles
[10–12], and other socio-demographic and maternal factors
[1, 13].
The World Health Organization (WHO) recommends
that mothers exclusively breastfeed their children during
* Luana Romão Nogueira
luanaromaon@hotmail.com
1 Center forExcellence inNutrition andFeeding Difficulties,
PENSI Institute, SãoPaulo, Brazil
2 Nutrition Course, Biological andHealth Sciences Center,
Mackenzie Presbyterian University, SãoPaulo, Brazil
3 Master’s Degree inDevelopmental Disorders, Mackenzie
Presbyterian University, SãoPaulo, Brazil
4 Center forExcellence inNutrition andFeeding Difficulties,
Federal University ofSao Paulo, SãoPaulo, Brazil

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the first 6months and, from 6months onwards, food intro-
duction should be started [14]. The low rates of exclu-
sive breastfeeding have been associated to a wide range
of physical, organic, and psychosocial problems [15].
However, studies linking exclusive breastfeeding (EBF) to
behavioral development is inconclusive [15], parental style
may have a significant relationship with EBF and the dura-
tion of breastfeeding, which might impact on psychosocial
child development [9, 16]. Children feeding difficulties
have been associated to parental styles, especially parents
that are more uninvolved and authoritarian [17, 18].
While there are a good number of studies evaluating
parental feeding behaviors, most of these studies have
focused entirely on feeding practices and inferred feeding
styles from these practices [19]. Therefore, Hughes etal.
[20] have developed a measure to identify parental feeding
styles similar to a typology of general parenting—Car-
egiver’s Feeding Styles Questionnaire (CFSQ) [21] and
adapted to the Brazilian context [22]. Since parental styles
are based on cross-classification of high and low scores
of demandingness (i.e., demands for the child to eat) and
responsiveness (i.e., sensitivity to the child’s individual
needs during eating), parents were categorized into four
feeding styles as follows: authoritative, authoritarian,
indulgent, and uninvolved [23].
Parents’ feeding practice style could be an important
pathway to improve early childhood nutrition in several
aspects. Parental feeding styles refer to the parental profile
which refers to the set of practices and behaviors to main-
tain or control the feeding context such as when, what, or
how much their children eat. Feeding styles can be classi-
fied into four categories; authoritative (high demand/high
response), authoritarian (high demand/low response),
indulgent (low demand/high response), and uninvolved
(low demand/low response) [20].
In a study of more than a thousand mothers in the UK
[24], it was found that more permissive and less involved
mothers felt positive about breastfeeding, but limited
associations were found between personality factors and
attitudes towards breastfeeding. Machado and collabora-
tors [25], in a Brazilian study with children with feeding
difficulties, showed that both authoritarian and indulgent
mothers breastfed exclusively for longer than negligent
mothers. There was a higher level of interaction with chil-
dren in the responsive parenting style compared to other
feeding styles.
Despite the fact that controlling over feeding might be
associated with the duration of EBF, consistent evidence to
support the relationship between breastfeeding and parental
styles in children with feeding difficulties is still lacking.
To address this, the purpose of this study was to examine
the prevalence of EBF and verify the associations between
EBF and its duration with parental styles among children
with feeding difficulties from a Brazilian reference center in
feeding difficulties.
Methods
Analyses were conducted using a cross-sectional retrospec-
tive data from outpatients from a reference center in nutri-
tion and feeding difficulties. The study was approved by the
Institutional Review Board (CAAE 50004821.3.0000.5567).
All study procedures were administered after parents and
children ≥ 7years of age had given written consent. Children
and adolescents aged up to 18years old, of both sexes, were
included in the study. Records that presented incomplete
data on exclusive breastfeeding and other outcomes assessed
in this study were excluded from the analysis.
Clinical protocol overview
The study used data collected from medical records referring
to the first consultation at the ambulatory service, which
assists parents/caregivers seeking for their kids’ treatment
with any complaint of a feeding difficulty and living in Bra-
zil. Feeding difficulties were classified according to Kezner
etal. [2] definition as picky/fussy eaters, fear of eating,
or limited appetite. Also, children with complaints of an
increased appetite were eligible for treatment. An increased
appetite can be interpreted by the parents as food selectiv-
ity (or being picky for certain foods). Thus, in the current
sample there were seven children that reported increased
appetite, and they were classified as picky/fussy (food selec-
tivity) eaters. Previous qualitative study [26] supports this as
parents have spoken about the difficulties of managing their
child’s appetite and of seeking help and treatment. The clini-
cal protocol used data from July 2014 to December 2019.
More details on the clinical protocol were published else-
where [27]. For this study, data from infants, children, and
adolescents with feeding difficulties were used, resulting in
a sample of 194 records.
Measures
Exposure
Total and exclusive breastfeeding were assessed by asking
the parent at the 1st clinical interview the following ques-
tion: “Did you breastfeed exclusively your kid?” and if,
yes “For how long (in months) you breastfed exclusively?”
Breastfeeding duration was coded into never, < 2.0months, 2
and 3months, 4 and 5months, and 6months. The categories
were based on Speyer etal.’s [14] study; the last category
(≥ 6.0months) reflected the current recommendations of the
WHO to EBF for the first 6months of baby’s life [14].

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Outcome
The outcome was parental styles measured by the “Caregiv-
er’s Feeding Styles Questionnaire (CFSQ)” developed by
Hughes etal. [20]. This was adapted and validated by Fon-
tanezi etal. [22]. This information was also collected from
medical records, as part of the outpatient care routine. The
CFSQ proposed to measure general feeding styles in parents
of pre-school children, consistent with a developmental par-
enting paradigm [21]. A cross-classification of high and low
scores based on median splits on the two subscales identi-
fied the four feeding styles: (i) authoritative (high on both),
(ii) authoritarian (high demandingness, and low responsive-
ness), (iii) indulgent (low demandingness, high responsive-
ness), and (iv) uninvolved (low on both). Confirmatory fac-
tor analyses supported the factorial integrity of the Brazilian
adapted version. Coefficient α values showed adequate inter-
nal consistency (α = 0.79) for the overall questionnaire.
Potential confounders
Potential confounders were chosen based on previous stud-
ies [15, 26–30] on associations with children’s behaviors
and exclusive breastfeeding. These include child’s age, sex,
ethnicity, birth weight (i.e., months), gestational weight gain
(i.e., < 9kg, 9–14kg, and ≥ 14kg) [31], place of birth, whether
child had siblings or lived in a single-parent household, mater-
nal education background (i.e., ≤ high school, some college/
undergraduate degree, or graduate degree), maternal psycho-
logical distress (i.e., yes or no), and family history of feeding
difficulties (i.e., yes or no). All these were pulled from the
clinical anamnesis with mothers at the first interview.
Maternal body mass index (BMI) (kg/m2) was derived
from maternal self-reported height and weight. They
were classified according to the World Health Organiza-
tion (WHO) cutoff points for adults [32] in underweight
(BMI ≤ 18.5kg/m2), normal weight (BMI 18.5–24.9kg/
m2), overweight (BMI 25.0–29.99kg/m2), and obesity
(BMI ≥ 30kg/m2). Self-reported BMI measurements were
validated against the measured BMI and height and showed
adequate validity and calibration for a Brazilian sample
(n = 856, 50.2% female, 42.7 ± 23.3years) [33].
Child’s weight and height were measured by a trained
physician during the medical appointment first visit. Weight
was measured to the nearest 0.1kg barefoot, in light clothing
using a portable digital scale (Omron HBF-2226), and height
was recorded to the nearest 0.1cm using a fixed stadiom-
eter (Sanny™ ES 204). BMI followed the standard equation
(weight (kg)/ height (m2)). Child BMI z-score was derived
using the Anthro Plus software developed by the World
Health Organization (WHO) in underweight ≤ − 2 z-score,
normal weight > − 2 to < + 1 z-score, overweight > + 1
to < + 2 z-score, and obesity ≥ + 2 z-score [34].
Statistical methods
Descriptive statistics were used to describe maternal and
children characteristics as mean (± standard error) for
continuous variables and frequency (%) for categorical
variables. Linear regression analyses were used to deter-
mine associations between EBF duration (in months)
with maternal and child characteristics. Like the previ-
ous study using the CFSQ [23] with over 128 US parents,
only three feeding styles could be entered simultaneously
into the regressions, because adding a fourth style (i.e.,
uninvolved) would provide no new information (if a par-
ent had a “1” on all three feeding style variables, the style
would uninvolved). Uninvolved feeding was therefore the
reference group in this regression. For all tests, a signifi-
cant level of p < 0.05 (5%) was considered as significant.
Data were analyzed using SAS on Demand software (SAS
Institute Inc., Cary, NC, USA).
Results
Socio‑demographic characteristics
Children with feeding difficulties and their characteris-
tics are described in Table1. Overall, children’s mean age
at the first visit was of 4.13 (95% CI 3.68–4.56) years.
Picky eaters (61.9%) were the most prevalent feeding dif-
ficulties reported by the parents/caregivers, followed by
limit appetite (30.9%), and fear of eating (4.6%). Overall,
19.23% of the children were never breastfed, and 52.31%
were exclusively breastfed for at least 6months. There
were no significant differences between feeding difficul-
ties and the time duration of EBF. Among all parents
interviewed, most of them were classified for authori-
tarian (31.96%) and indulgent (31.44%) parental styles,
while only 9.28% were uninvolved. Picky-eating children
were older (M = 4.63; 95% CI 4.10, 5.18years), presented
higher weight (M = 20.21; 95% CI 18.09, 22.33kg), and
height (M = 105.79; 95% CI 101.83, 109.75cm) than the
other children with the other feeding difficulties. Children
classified as fear of eating were longer totally breastfed
(M = 17.00; 95% CI 2.17, 31.83months) as compared to
other feeding difficulties.
Exclusive breastfeeding, developmental phase
forfeeding difficulties, andparental styles
Figure1 shows the prevalence for duration of exclusive
breastfeeding and parental styles. Although non-signifi-
cant results, authoritative mothers (67.65%) had a higher
prevalence for EBF for 6months, while uninvolved mothers

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Table 1 Sample characteristics and associations with feeding difficulties in children from a reference center in nutrition and feeding difficulties.
São Paulo 2014–2019
Note: CI confidence interval
Characteristics Total (n = 194) Picky eaters (n = 120) Fear of eating (n = 9) Limit appetite (n = 65)
Mean (95% CI)
Child age in years 4.13 (3.68, 4.56) 4.63 (4.10, 5.18) 2.67 (1.71, 3.62) 2.79 (2.18, 3.39)
Birth weight, kg 3.11 (3.05, 3.17) 3.14 (3.07, 3.22) 2.88 (2.68, 3.07) 3.06 (2.95, 3.17)
Child actual weight, kg 18.13 (16.43, 19.84) 20.21 (18.09, 22.33) 12.78 (9.04, 16.51) 12.32 (10.78, 13.86)
Child actual height, cm 100.86 (97.52, 104.20) 105.79 (101.83, 109.75) 91.00 (78.90, 103.10) 88.92 (83.97, 93.87)
Maternal age, years 36.64 (35.89, 37.38) 36.85 (35.93, 37.77) 34.83 (31.76, 37.90) 35.83 (34.44, 37.21)
Exclusive breastfeeding, months 3.24 (2.85, 3.63) 3.36 (2.85, 3.87) 2.89 (1.07, 4.71) 3.10 (2.40, 3.80)
Total breastfeeding, months 8.30 (6.71, 9.89) 8.67 (6.85, 10.48) 17.00 (2.17, 31.83) 4.76 (2.94, 6.59)
% (Frequency)
Child sex, female 34.02 (66) 26.67 (32) 33.33 (3) 48.33 (29)
Place of birth, São Paulo 88.89 (168) 86.21 (100) 88.89 (8) 94.92 (56)
Family history for feeding difficulty, yes 46.94 (69) 53.93 (48) 50.00 (3) 34.69 (17)
Premature, yes 28.35 (55) 28.33 (34) 55.55 (5) 22.73 (15)
Siblings, yes 68.06 (130) 65.25 (77) 66.67 (6) 71.19 (42)
Maternal psychological distress, yes 21.59 (38) 23.58 (25) 11.11 (1) 21.43 (12)
Post-partum depression, yes 19.42 (20) 17.81 (13) 25.00 (1) 23.08 (6)
Gestational weight gain, kg
< 9kg 11.69 (18) 12.63 (12) 14.29 (1) 6.25 (3)
9–14kg 52.60 (81) 52.63 (50) 42.86 (3) 56.25 (27)
≥ 14kg 35.71 (55) 34.74 (34) 42.86 (3) 37.50 (18)
Parental education background
≤ High school 7.61 (14) 8.85 (10) 11.11 (1) 5.17 (3)
College/bachelor degree 92.39 (170) 92.39 (170) 88.89 (8) 94.83 (55)
Time of exclusive breastfeeding
Never breastfeed
< 2months
2–3months
4–5months
6months
19.23 (25)
6.15 (8)
11.54 (15)
10.77 (14)
52.31 (68)
19.54 (17)
3.45 (3)
12.64 (11)
6.90 (6)
57.47 (50)
–-
14.29 (1)
–-
14.29 (1)
71.43 (5)
23.58 (8)
11.74 (4)
8.82 (3)
20.59 (7)
35.29 (12)
Developmental phase of feeding difficulties
Introduction to foods 10.36 (20) 4.17 (5) 22.22 (2) 22.03 (13)
Complementary foods 37.82 (73) 32.50 (39) 44.44 (4) 50.85 (30)
Eating with the family 51.81 (100) 63.33 (76) 33.33 (3) 27.12 (16)
Parental styles
Authoritative 27.32 (53) 30.83 (37) 22.22 (2) 23.33 (14)
Authoritarian 31.96 (62) 30.00 (36) 33.33 (3) 36.67 (22)
Indulgent 31.44 (61) 30.00 (36) 33.33 (3) 31.67 (19)
Uninvolved 9.28 (18) 9.17 (11) 11.11 (1) 8.33 (5)
Children weight status
Underweight 5.82 (11) 4.24 (5) 11.11 (1) 7.02 (4)
Normal weight 86.24 (163) 85.59 (101) 88.89 (8) 92.98 (53)
Overweight 4.23 (8) 5.08 (6) –- –-
Obesity 3.70 (7) 5.08 (6) –- –-
Maternal weight status
Underweight 2.21 (3) 22.22 (2) –- 2.86 (1)
Normal weight 61.03 (83) 61.11 (55) 50.00 (4) 68.57 (24)
Overweight 27.21 (37) 28.89 (26) 37.50 (3) 17.14 (6)
Obesity 9.56 (13) 7.78 (7) 12.50 (1) 11.43 (4)

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(33.33%) had higher prevalence for never exclusively breast-
fed their children.
Associations withexclusive breastfeeding
andparental styles andfeeding difficulties
At both unadjusted and adjusted models, children who
were longer EBF was positively associated with having
more indulgent (ß = 2.20, 95% CI 0.67, 3.73, authoritative
(ß = 2.15; 95% CI 0.62, 3.68), and authoritarian mothers
(ß = 1.92; 95% CI 0.37, 3.47) as compared to uninvolved
parents. On the other hand, no significant associations were
found between children who were longer EBF and feeding
difficulties. Results are presented in Table2.
Discussion
Feeding difficulties in childhood is a condition with multi-
factorial etiology. The presence of breastfeeding and parent-
ing style are related to eating behaviors [35]. Breastfeeding
is likely to produce a protective effect against the devel-
opment of selective eating in childhood [36]. Most parents
in this study reported that their children were exclusively
breastfed 6months and authoritative parents had a higher
prevalence for being longer EBF for 6months. Uninvolved
parents’ higher prevalence forever breasted their children.
The NOURISH study had 458 mothers enrolled in a trial
provided data on breastfeeding at child age 4, 14, and
24months, and on feeding practices at 24months. The
results demonstrate an association between longer breast-
feeding duration and authoritative feeding practices charac-
terized by responsiveness associations between breastfeed-
ing durations [37]. Moreover, it was found that children with
a fear of eating were totally breastfed for a shorter time.
Babies characterized with eating phobia or fear of feeding
18.42
5.26
13.16 13.16
50.00
17.65
2.94
8.82
2.94
67.65
17.39
10.87 8.70
13.04
50.00
33.33
0.00
25.00
16.67
25.00
Never 0-2m 2-3.9m 4-5.9m
Authoritarian Authoritative Indulgent Uninvolved
Fig. 1 Prevalence of exclusive breastfeeding and parental feeding style among children with feeding difficulties. São Paulo, Brazil. *There were
no significant p-values between variables
Table 2 Associations between exclusive breastfeeding and parental
styles and feeding difficulties. São Paulo, Brazil, 2014–2019
Note: CI confidence interval
*p < 0.05, **p < 0.01, ***p < 0.001
1 Adjusted for child sex, age, height and weight, total time for breast-
feeding, and developmental phase for feeding difficulties
Unadjusted Adjusted1
ß (95%CI)
Parental style Exclusive breastfeeding
Authoritarian 1.92 (0.36, 3.47)* 1.92 (0.37, 3.47)*
Authoritative 2.15 (0.62, 3.68)** 2.15 (0.62, 3.68)**
Indulgent 2.14 (0.61, 3.67)** 2.20 (0.67, 3.73)**
Uninvolved Ref Ref
Feeding difficulties
Picky/fussy eater 0.26 (− 0.60, 1.12) 0.20 (− 0.66, 1.07)
Fear of eating − 0.21 (− 2.15, 1.72) − 0.27 (− 2.20, 1.67)
Limit appetite Ref Ref

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can be an extremely resistant to feeding, refusing a type of
food after a bad experience such as vomiting or pain [4].
These findings are very important for the prevention of feed-
ing difficulties in young children and for encouraging EBF
and longer time for total breastfeeding during infancy and
childhood.
Picky eaters were very common in the study sample,
reaching 61%, while children with fear of eating reached
only 4% of the entire population. Previous reviews [5, 6]
have also showed that feeding difficulties may be a transitory
problem during infancy and childhood, and several factors
might be associated to exclusive breastfeeding. As feed-
ing difficulties being a transitory problem, do not exclude
the idea that these should be taken into full consideration
by a multi-disciplinary team to evaluation and treatment.
These findings emphasize the need for targeted interven-
tions to encourage exclusive breastfeeding during infancy to
reduce the burden of later feeding difficulties and its related
consequences.
Authoritarian and uninvolved parental practices are
differently associated with EBF duration in children with
feeding difficulties. This finding is consistent with few
previous studies [11, 18, 38] that have also described par-
ents’ styles and associated factors. Certain level of parental
control (e.g., authoritative style) was positively associated
with longer time for exclusive breastfeeding, as compared
to non-controlling parents (uninvolved parents). Indulgent
parents, i.e., low demandingness and high responsiveness,
were the ones that showed the highest ß values with longer
EBF. Therefore, parents that have a positive controlling style
[23] may increase the chances to meet the recommendations
of the World Health Organization for exclusive breastfeeding
for 6months [14]. Other studies [16, 23] show that indul-
gent parents can positively influence their children’s health
compared to other parenting styles. Positive parental styles
suggest that younger children tend to gain more autonomy
over their lifestyle behaviors as older child, thus, the role
of earlier parental monitoring are important to predict later
positive outcomes, fostering a healthy growth, development,
and weight status [23].
Parental styles with certain control over feeding (i.e.,
authoritarian and authoritative) [39] might suggest greater
psychological distress during the first 6months, and longer
duration of breastfeeding.However, differently from authori-
tative style (i.e., higher demandingness and responsiveness),
authoritarian style (i.e., lower responsiveness but higher
demandingness) may not always be benign. Indeed, psy-
chological distress at 6months also contributes to the food
restriction and negatively pressure over their infants feed-
ing practices, both may lead to feeding difficulties during
childhood [40].
Previous longitudinal studies showed that a longer dura-
tion of EBF was associated to more responsive feeding styles
[17, 41] and this may echo to children’s satiety cues [41].
Thus, feeding mode affects mothers/parents’ styles and high-
lighting the need for future national longitudinal studies to
demonstrate how feeding interactions affect the formation
of eating habits from early childhood [40]. For the authors’
knowledge, this was one of the few Brazilian studies that
aimed to understand if parental styles are associated with the
duration of EBF. More studies are needed to investigate this
relationship. It is imperative to employ study designs that
can disentangle relative effects of feeding style and socio-
demographic covariates on the development of feeding inter-
actions and outcomes across childhood [40]. It is important
to mention that 2.4% of the sample (n = 8; results not shown)
reported EBF for more than 6months. It is hypothesized
that, due to the child’s feeding difficulty, some families may
extend the EBF because they consider a greater guarantee
of food and nutrition even after 6months.
Strengths of the study include the use of well-known,
validated measures of parental styles. Parental feeding styles
were measured through a questionnaire validated with par-
ents of young children awaiting at the emergency room of
a private children hospital in Brazil. Data were collected
from parents at their first clinical appointment by a multi-
disciplinary team from a reference center in treating children
with feeding difficulties. However, this study is not without
limitations. First, the cross-sectional design precludes infer-
ence of causal relationships between breastfeeding, parental
styles, and types of feeding difficulties. Parental style might
have changed over time and therefore associations with EBF
might suffer from this change. Second, the generalizability is
limited due the inclusion of children recruited from a private
feeding difficulty center in a large urban city in the southeast
part of Brazil. Third, likewise, most of the parenting styles
studies, measurements were self-reported and not directly
observed, so social desirability bias may have been present.
Fourth, the sample was relatively small; a large sample size
could have yielded other associations. Further studies should
also investigate EBF and total breastfeeding duration and
parental styles using a longitudinal design. Fifth, the sample
included children and adolescents with feeding difficulties
complaints. For adolescents, it is possible to have a greater
memory bias in relation to information on breastfeeding and
food introduction since they occurred longer ago.
Conclusion
About 19% of the children were never breastfed, and 52%
were exclusively breastfed for at least 6months. The current
results showed that authoritarian, authoritative, and indul-
gent parental styles were positively associated with longer
duration for exclusive breastfeeding practices in children
with feeding difficulties. Therefore, specific guidelines may

Nutrire (2023) 48:50
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Page 7 of 8 50
be necessary, aiming at the success of this very signifi-
cant period for mother and child. Interventions to promote
responsive eating practices are needed to improve the breast-
feeding and prevention of feeding difficulties.
Authors’ contributions PM and VF participated in all stages of the
study. ARA, LRN and MF carried out revision of the text and addition
of significant parts.
Availability of data and materials Not applicable.
Declarations
Ethics approval The study was approved by the Institutional Review
Board (CAAE 50004821.3.0000.5567). All study procedures were
administered after parents and children ≥ 7years of age had given
written consent.
Competing interests MF has Abbott, Nestlé and Danone research and
conference support. The other authors declared that there is no potential
conflict of interest regarding this article.
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