Estimated causal effects of complementary feeding behaviors on early childhood diet quality in a US cohort.

View Abstract


Complementary feeding (CF) provides an opportunity to shape children's future dietary habits, setting the foundation for good nutrition and health.


We estimated effects of 3 CF behaviors on early childhood diet quality using inverse probability (IP) weighting of marginal structural models (MSMs).


Among 1,041 children from the Boston-area Project Viva cohort, we estimated effects on the mean Youth Healthy Eating Index (YHEI) score in early childhood of: 1) delayed (≥12mo, vs. early [<12mo]) introduction of sweets and fruit juice; 2) continued (vs. ceased) offering of initially refused foods; and 3) early (<12mo, vs. late [≥12mo]) introduction of flavor/texture variety. Mothers reported CF behaviors at 1y and completed food frequency questionnaires for children in early childhood (median age 3.1y). We estimated average treatment effects (ATEs) using IP weighting of MSMs to adjust for both confounding and selection bias due to censored outcomes and examined effect modification by child sex and breastfeeding (BF) vs. formula feeding (FF) at 6mo.


Twelve percent of mothers delayed introducing sweets/fruit juice, 93% continued offering initially refused foods, and 32% introduced flavor/texture variety early. The mean±SD YHEI score was 52.8±9.2 points. In adjusted models, we estimated a higher mean YHEI score with delayed (vs. early) sweets and fruit juice among BF children (ATE 4.5 points, 95% CI: 1.0, 7.4), as well as with continued (vs. ceased) offering of refused foods among females (ATE 5.4 points, 95% CI: 0.8, 9.1). The ATE for early (vs. late) flavor/texture variety was 1.7 points (95% CI: 0.3, 3.2) overall and stronger (2.8 points, 95% CI: 0.7, 5.1) among the FF group.


Delayed introduction of sweets/juice, continued offering of refused foods, and early flavor/texture variety may all result in higher childhood diet quality. Effects may depend on child sex and infant breastfeeding status. Clinical Trial Registry information: Project Viva is registered at as NCT02820402.

Am J Clin Nutr
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Estimated causal effects of complementary feeding behaviors on early childhood diet quality in a US cohort.
Switkowski KM, Aris IM, Gingras V, Oken E, Young JG