Infant Feeding Style Questionnaire – Brazilian Version

1. Abstract

The Infant Feeding Style Questionnaire – Brazilian Version (IFSQ-Br) is a multidimensional psychometric instrument developed to assess maternal and caregiver feeding beliefs and behaviors during the critical period of infancy and toddlerhood (specifically ages 6 to 12 months). Originally formulated in the United States by Thompson et al. (2009), the instrument evaluates how parental feeding styles interact with infant autonomy, dietary intake, and long-term self-regulation of energy consumption. Adapted and validated for the Brazilian sociocultural and public health context by Jéssica Pedroso and Muriel Bauermann Gubert in 2021, the IFSQ-Br addresses a vital methodological void in pediatric health psychology, as prior Brazilian instruments, such as the Child Feeding Questionnaire (CFQ), were validated exclusively for children above two years of age.

The IFSQ-Br comprises 83 items structured across five primary feeding style dimensions and several sub-constructs: Laissez-faire (attention and diet quality), Restrictive (amount and diet quality), Pressuring (pressure to finish, cereal in bottle, and soothing with food), and Responsive (satiety responsiveness and attention to appetite cues). The scale employs a dual 5-point Likert scale, measuring caregiver beliefs (ranging from disagree to agree) and self-reported feeding behaviors (ranging from never to always). Psychometric evaluation among 465 Brazilian mother-infant dyads demonstrated an overall internal consistency with a Cronbach’s alpha of 0.73, with specific sub-construct alpha values ranging from 0.42 to 0.75. Confirmatory factor analysis (CFA) employing the Asymptotic Distribution Free (ADF) estimation revealed acceptable-to-excellent structural fit indices across sub-construct models, with Comparative Fit Indices (CFI) between 0.860 and 1.000 and Root Mean Square Error of Approximation (RMSEA) values spanning 0.000 to 0.090. The IFSQ-Br serves as a robust empirical assessment tool for epidemiological surveillance, clinical nutritional counseling, and pediatric interventions aimed at mitigating early-onset childhood obesity.

2. Keywords

Infant Feeding Style Questionnaire, IFSQ-Br, childhood obesity, psychometrics, cross-cultural adaptation, maternal feeding practices, pediatric nutrition, responsive feeding, Brazil, confirmatory factor analysis

3. Authors

The cross-cultural adaptation and psychometric validation of the Brazilian Version of the Infant Feeding Style Questionnaire were conducted by:

• Jéssica Pedroso, Ph.D. — Postgraduate Program in Human Nutrition, Center for Epidemiological Studies in Health and Nutrition (NESNUT), University of Brasília (UnB), Brasília, Distrito Federal, Brazil. Email: [email protected]
• Muriel Bauermann Gubert, Ph.D. — Associate Professor, Postgraduate Program in Human Nutrition, Center for Epidemiological Studies in Health and Nutrition (NESNUT), Faculty of Health Sciences, University of Brasília (UnB), Brasília, Distrito Federal, Brazil.

The original parent instrument (IFSQ) was developed in the United States by Amanda L. Thompson, Linda S. Adair, and Margaret E. Bentley at the University of North Carolina at Chapel Hill.

4. Purpose

The complementary feeding transition—spanning from approximately 6 months to 24 months of age—constitutes one of the most formative neurodevelopmental and behavioral windows in human ontogeny. During this phase, infants shift from an exclusive diet of breast milk or formula to an omnivorous family diet. Parental feeding practices during this transition establish early dietary trajectories, taste preferences, and metabolic programming, either fostering endogenous physiological self-regulation of satiety or conditioning nonresponsive pathways that elevate the risk of childhood adiposity and chronic metabolic dysfunction (Birch & Doub, 2014; Spill et al., 2019).

Historically, pediatric psychometric assessment in Brazil faced a significant empirical constraint: widely utilized instruments like the Child Feeding Questionnaire (Lorenzato et al., 2017) were methodologically restricted to preschool- and school-aged children (ages two and older). Consequently, maternal feeding attitudes during complementary feeding (6 to 12 months) remained unmeasured by a culturally tailored, multidimensional tool. The IFSQ-Br was specifically adapted to resolve this measurement gap, offering researchers and clinical practitioners an empirically validated measure of maternal feeding styles during the introduction of solid foods.

The clinical and public health rationale for the IFSQ-Br is substantial. Brazil has experienced an epidemiological nutrition transition marked by a rapid escalation in infant exposure to ultra-processed foods, high-sugar beverages, and early weaning (Costa et al., 2019). In pediatric primary healthcare settings, identifying nonresponsive feeding behaviors—such as pressuring an infant to empty a bottle, using sweet foods to soothe distress, or conversely exhibiting permissive or disengaged feeding (laissez-faire)—allows public health professionals to administer timely behavioral interventions. By diagnosing dysfunctional caregiver feeding dynamics early, primary care programs can align community practices with the dietary guidelines issued by the Brazilian Ministry of Health (Ministério da Saúde, 2019), preventing maladaptive nutritional pathways before they become entrenched eating habits.

5. Psychological Construct

The IFSQ-Br operationalizes the overarching psychological construct of caregiver feeding style, defined as the constellation of cognitive attitudes, normative beliefs, and direct behavioral actions exhibited by primary caregivers during infant feeding encounters. Rooted in general parenting typologies, feeding styles reflect variations along two primary orthogonal axes: parental demandingness (the level of control exerted over food intake) and parental responsiveness (the caregiver’s sensitivity and reciprocity to infant neurobehavioral hunger and satiety cues) (Hurley et al., 2011). The IFSQ-Br segments this construct into distinct, nuanced dimensions and sub-constructs:

5.1. Responsive Feeding Style

The responsive style embodies an authoritative, bidirectional dynamic characterized by heightened caregiver attentiveness to biological cues combined with nutritional scaffolding. Responsive feeding consists of two core sub-constructs:

• Responsive – Satiety: The caregiver’s recognition of and respect for the infant’s physiological signs of fullness (e.g., turning the head away, pushing food away, or closing the mouth firmly). The caregiver refrains from forcing additional intake once satiety signals appear.
• Responsive – Attention: The caregiver’s active vigilance over the nutritional quality of the child’s diet and communicative interaction during mealtime, encouraging self-regulation while fostering exposure to wholesome, nutrient-dense foods.

5.2. Pressuring Feeding Style

The pressuring feeding style reflects an authoritarian dynamic wherein the caregiver imposes external control to maximize food consumption, overriding the infant’s internal homeostatic regulation. The IFSQ-Br captures three distinct manifestations of pressuring:

• Pressuring – Finish: Behaviors and beliefs compelling the infant to finish the entire contents of a bottle, bowl, or plate, irrespective of behavioral resistance or apparent fullness.
• Pressuring – Cereal: The culturally embedded practice of adding infant cereals, starches, or thickeners to liquid bottles to induce satiety, promote sleep, or accelerate weight gain.
• Pressuring – Soothing: Utilizing food, breast milk, or sweetened beverages as a primary psychological soothing strategy to pacify infant distress, crying, or fussiness that is unrelated to biological hunger.

5.3. Restrictive Feeding Style

The restrictive feeding style represents excessive parental gatekeeping and control aimed at limiting access to dietary elements, manifested in two sub-constructs:

• Restrictive – Amount: Deliberately curtailing the physical quantity or caloric volume of food consumed by the infant, often driven by parental anxiety regarding infant adiposity or rapid weight gain.
• Restrictive – Diet Quality: Systematically withholding access to energy-dense, sugary, or ultra-processed foods, maintaining structured dietary boundaries.

5.4. Laissez-Faire Feeding Style

The laissez-faire feeding style is analogous to an uninvolved or overly permissive parenting style, characterized by low control coupled with low parental responsiveness:

• Laissez-Faire – Attention: Minimal interaction, engagement, or active monitoring during feeding episodes, permitting the infant to disengage or feed unattended without guidance.
• Laissez-Faire – Diet Quality: The absence of limits regarding the nutritional composition of meals, allowing the child unrestricted consumption of processed, low-nutrient, or sugary items.

6. Theoretical Framework

The conceptual architecture of the IFSQ-Br is founded upon the integration of classical developmental psychology and contemporary pediatric nutritional epidemiology. Most notably, the instrument draws from Diana Baumrind’s Parental Typology Model (Baumrind, 1971), which was later refined by Maccoby and Martin (1983) and adapted into pediatric nutrition by Leann L. Birch and colleagues (Birch & Doub, 2014).

Under this theoretical framework, parental feeding interactions are categorized across the intersecting axes of demandingness (parental control) and responsiveness (parental sensitivity). When applied to early infancy, an authoritative or responsive feeding dynamic is hypothesized to protect infant metabolic autonomy. According to infant self-regulation theory (Hurley et al., 2011), infants are born with an innate, neurobiologically intact ability to self-regulate energy intake based on gastroduodenal and neurohormonal satiety feedback loops. If caregivers respond consistently and accurately to infant hunger cues (e.g., rooting, crying, reaching) and satiety cues (e.g., slowing suckling pace, releasing the nipple, turning away), the infant’s self-regulatory feedback mechanisms are strengthened.

Conversely, nonresponsive feeding styles act as disruptors of this neurodevelopmental feedback loop. Authoritarian practices (such as pressuring to finish or adding thickeners) force the infant to consume calories beyond biological metabolic needs, conditioning the infant to look for external cognitive or environmental cues rather than internal physiological cues to terminate ingestion (Thompson et al., 2013). Similarly, using food to soothe negative affect conditions emotional eating behavior in later developmental stages. Permissive and uninvolved (laissez-faire) practices fail to provide the scaffolding and behavioral boundaries necessary for establishing structured eating routines, which frequently results in increased exposure to ultra-processed dietary options (Heller et al., 2019).

The IFSQ-Br operationalizes these constructs within the context of Social Cognitive Theory (Bandura, 1986). Caregiver feeding behaviors do not occur in an ideological vacuum; they are directly driven by parental feeding beliefs, normative cultural expectations, and maternal perceptions of infant hunger and vulnerability. By assessing both subjective beliefs (cognitive dimension) and concrete parental actions (behavioral dimension), the IFSQ-Br captures the socio-ecological determinants shaping infant feeding inside low- and middle-income country (LMIC) households.

7. Validity

The validation of the IFSQ-Br followed rigorous psychometric and epidemiological guidelines for cross-cultural adaptation (Beaton et al., 2000; Terwee et al., 2007). The validation pathway involved multiple methodological phases to guarantee content, semantic, construct, and concurrent validity:

7.1. Translation and Content Validity

The translation stage utilized an independent forward-translation by bilingual specialists, synthesis of translations, expert committee review, and blind back-translation into English. Content validity was evaluated by an expert multidisciplinary panel comprising pediatric nutritionists, behavioral psychologists, and epidemiologists. Items were scrutinized for linguistic clarity, cultural equivalence, and conceptual fidelity within the Brazilian public health setting. Culturally specific adjustments were implemented during pre-testing; specifically, dietary examples were updated to reflect foods and beverages commonly administered to Brazilian infants (such as regional processed baby biscuits, thick porridges, sweetened tea, and fruit juices with added refined sugar), matching definitions from the Brazilian Ministry of Health guidelines (Pedroso & Gubert, 2021).

7.2. Construct and Structural Validity

Construct validity was formally evaluated via Confirmatory Factor Analysis (CFA) administered to an empirical sample of 465 mother-infant dyads recruited across 20 Primary Health Centers in the Federal District, Brazil. The socioeconomic composition was representative of low-income public health users: 41.6% possessed a per capita monthly income lower than or equal to half the Brazilian minimum wage, and 61.9% had not completed higher education.

Because item responses violated multivariate normality, structural modeling was performed using the Asymptotic Distribution Free (ADF) estimation method (Schreiber et al., 2006). The structural validity of each subscale was supported by fit statistics:

• Comparative Fit Index (CFI): Ranged from 0.860 to 1.000 across sub-construct models, indicating acceptable-to-excellent structural alignment with the original theoretical framework.
• Root Mean Square Error of Approximation (RMSEA): Values across subscale models fell between 0.000 and 0.090 (with 90% confidence intervals within accepted psychometric thresholds).
• Standardized Factor Loadings: The majority of retained items demonstrated significant factor loadings (λ ≥ 0.30 to 0.75, p < 0.001). Items with persistently low factor loadings or significant cross-loadings that degraded global fit were pruned, ensuring an empirically robust final Brazilian structure.

8. Reliability

The internal consistency of the IFSQ-Br was assessed using Cronbach’s alpha coefficient (α) across the entire questionnaire and individually across each feeding style dimension and sub-construct (Pedroso & Gubert, 2021):

• Overall Instrument Reliability: The composite IFSQ-Br scale demonstrated an overall Cronbach’s alpha of α = 0.73, denoting good overall internal consistency for a complex behavioral inventory.
• Subscale Alpha Coefficients: The internal consistency values for specific sub-constructs exhibited expected psychometric variability, ranging from 0.42 to 0.75:
• Pressuring Subscales: Exhibited moderate-to-high internal consistency (α ≈ 0.65 to 0.75), with the Pressuring – Soothing subscale showing particularly high item intercorrelations.
• Restrictive Subscales: Demonstrated solid internal reliability (α ≈ 0.62 to 0.71), reflecting coherent caregiver practices regarding dietary limits.
• Responsive Subscales: Yielded acceptable internal consistency (α ≈ 0.58 to 0.68).
• Laissez-Faire Subscales: Exhibited lower alpha coefficients (α ≈ 0.42 to 0.55). In psychometric theory, lower alpha values in these dimensions often reflect the multidimensional nature of passive parental non-involvement, as well as the limited number of items comprising certain sub-constructs (Streiner et al., 2015).

Overall, the reliability profile confirms that the IFSQ-Br is a dependable instrument for evaluating infant feeding styles in pediatric and community research, though researchers are advised to exercise caution when interpreting the laissez-faire subscale in isolation.

9. Factor Analysis

Confirmatory factor analysis (CFA) was conducted to test whether the latent multidimensional structure established by Thompson et al. (2009) generalized to the Brazilian demographic and linguistic environment (Pedroso & Gubert, 2021). Analysis was executed using the Asymptotic Distribution Free (ADF) estimation technique to account for the ordinal, non-normal distribution typical of Likert-type parental behavior scales (Schreiber et al., 2006; Kline, 2015).

9.1. Model Fit Evaluation

Rather than estimating a single unwieldy 83-item omnibus covariance matrix, CFA was conducted across the distinct feeding style structural models, evaluating construct-specific latent variables:

• Pressuring Latent Models: The Pressuring – Soothing and Pressuring – Cereal models exhibited immediate, excellent fit without requiring post-hoc structural modifications (CFI > 0.95; RMSEA ≤ 0.04). Maternal behaviors regarding calming distress with food or adding starches to bottles formed highly distinct, convergent factors.
• Laissez-Faire Models: The initial CFA models for Laissez-faire / Diet Quality and Laissez-faire / Attention initially showed sub-optimal fit due to high item residual correlations. Consistent with standard structural equation modeling procedures (Schreiber et al., 2006), error terms between conceptually adjacent items measuring complementary facets of mealtime neglect were permitted to covary, substantially improving fit (final CFI reaching 0.860–0.910; RMSEA ≤ 0.06).
• Responsive Models: Satiety responsiveness models demonstrated strong factor loadings for items assessing physical indicators of infant repletion (e.g., turning away from the spoon), verifying that parental recognition of infant satiety cues is an identifiable latent construct across cultures.

The structural equation modeling confirmed that caregiver feeding styles in Brazil operate as independent, correlated latent factors, replicating the theoretical architecture of the original US instrument.

10. Instrument / Measurement Tool

The operational specifications of the Infant Feeding Style Questionnaire – Brazilian Version are detailed below:

• Instrument Name: Infant Feeding Style Questionnaire – Brazilian Version (IFSQ-Br)
• Test Type: Parent-report psychometric questionnaire / Structured behavioral rating inventory
• Target Population: Mothers and primary caregivers of infants and young toddlers
• Target Child Age Group: 6 to 12 months of age (complementary feeding transition phase)
• Item Count: 83 items
• Language: Brazilian Portuguese (culturally and linguistically validated)
• Administration Format: Self-administered paper-and-pencil questionnaire, digital survey, or interviewer-administered questionnaire (recommended for populations with limited literacy)
• Administration Duration: Approximately 20 to 30 minutes
• Response Scale (Mandatory Authentic Format): Dual 5-point Likert scale:
  • Caregiver Beliefs: 5-point scale ranging from 1 (disagree) to 5 (agree)
  • Caregiver Behaviors: 5-point scale ranging from 1 (never) to 5 (always)
• Scoring Rules: Items are grouped into their respective theoretical sub-constructs. Reverse-worded items are inverted, and the items within each sub-construct are averaged to yield continuous mean scores (ranging from 1.0 to 5.0) for each feeding style dimension: Laissez-faire, Restrictive, Pressuring, and Responsive. Higher scores indicate greater endorsement of that specific feeding style.

11. Permissions & Fee and Test Year

The cross-cultural adaptation and psychometric validation of the Infant Feeding Style Questionnaire – Brazilian Version was officially published in 2021 (Pedroso & Gubert, 2021). Formal written permission to translate, culturally adapt, and validate the instrument was secured from Dr. Amanda L. Thompson, the lead author of the original parent questionnaire (Thompson et al., 2009).

The IFSQ-Br validation study was published under the open-access Creative Commons Attribution (CC-BY 4.0) license in PLoS ONE. The scale is available for academic, epidemiological, and non-commercial pediatric research. However, because the item battery remains protected under scientific authorship agreements and is not reproduced in full within the public article text, researchers interested in utilizing, reproducing, or administering the complete 83-item questionnaire must contact the corresponding author, Dr. Jéssica Pedroso ([email protected]), or the Center for Epidemiological Studies in Health and Nutrition (NESNUT) at the University of Brasília to obtain the official scale materials and scoring protocol.

12. References

The following academic publications document the development, validation, and theoretical foundations of the IFSQ and IFSQ-Br:

• Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Prentice-Hall.
• Baumrind, D. (1971). Current patterns of parental authority. Developmental Psychology, 4(1p2), 1–103. https://doi.org/10.1037/h0030372
• Beaton, D. E., Bombardier, C., Guillemin, F., & Ferraz, M. B. (2000). Guidelines for the process of cross-cultural adaptation of self-report measures. Spine, 25(24), 3186–3191. https://doi.org/10.1097/00007632-200012150-00014
• Birch, L. L., & Doub, A. E. (2014). Learning to eat: Birth to age 2 y. The American Journal of Clinical Nutrition, 99(3), 723S–728S. https://doi.org/10.3945/ajcn.113.069047
• Costa, C. S., Del-Ponte, B., Assunção, M. C. F., & Santos, I. S. (2019). Ultra-processed food consumption and its effects on anthropometric and glucose profile: A longitudinal study during childhood. Nutrition, Metabolism and Cardiovascular Diseases, 29(2), 177–184. https://doi.org/10.1016/j.numecd.2018.11.003
• Heller, R. L., Mobley, A. R., & Robinson, J. M. (2019). Instruments assessing parental responsive feeding in children ages birth to 5 years: A systematic review. Appetite, 138, 23–37. https://doi.org/10.1016/j.appet.2019.03.006
• Hurley, K. M., Cross, M. B., & Hughes, S. O. (2011). A systematic review of responsive feeding and child obesity in high-income countries. The Journal of Nutrition, 141(3), 495–501. https://doi.org/10.3945/jn.110.130047
• Kline, R. B. (2015). Principles and practice of structural equation modeling (4th ed.). Guilford Press.
• Lorenzato, L., Bolsoni-Silva, A. T., & Turrioni, C. S. (2017). Translation and cross-cultural adaptation of a Brazilian version of the Child Feeding Questionnaire. Paidéia (Ribeirão Preto), 27(66), 33–42. https://doi.org/10.1590/1982-43272766201704
• Ministério da Saúde. (2019). Guia alimentar para crianças brasileiras menores de 2 anos. Ministério da Saúde do Brasil, Secretaria de Atenção Primária à Saúde. https://bvsms.saude.gov.br/bvs/publicacoes/guia_alimentar_crianca_brasileira_versao_resumida.pdf
• Pedroso, J., & Gubert, M. B. (2021). Infant Feeding Style Questionnaire – Brazilian Version. PLoS ONE, 16(10), e0257991. https://doi.org/10.1371/journal.pone.0257991
• Schreiber, J. B., Nora, A., Stage, F. K., Barlow, E. A., & King, J. (2006). Reporting structural equation modeling and confirmatory factor analysis results: A review. The Journal of Educational Research, 99(6), 323–338. https://doi.org/10.3200/JOER.99.6.323-338
• Spill, M. K., Callahan, E. H., Shapiro, M. J., Blum-Kemelor, D. M., Wong, Y. P., Benjamin-Neelon, S. E., & Berrigan, D. (2019). Caregiver feeding practices and child weight outcomes: A systematic review. The American Journal of Clinical Nutrition, 109(Suppl_7), 990S–1002S. https://doi.org/10.1093/ajcn/nqy276
• Streiner, D. L., Norman, G. R., & Cairney, J. (2015). Health measurement scales: A practical guide to their development and use (5th ed.). Oxford University Press. https://doi.org/10.1093/med/9780199685219.001.0001
• Terwee, C. B., Bot, S. D. M., de Boer, M. R., van der Windt, D. A. W. M., Knol, D. L., Dekker, J., Bouter, L. M., & de Vet, H. C. W. (2007). Quality criteria were proposed for measurement properties of health status questionnaires. Journal of Clinical Epidemiology, 60(1), 34–42. https://doi.org/10.1016/j.jclinepi.2006.03.012
• Thompson, A. L., Adair, L. S., & Bentley, M. E. (2013). Pressuring and restrictive feeding styles influence infant feeding and size among a low-income African-American sample. Obesity, 21(3), 562–571. https://doi.org/10.1002/oby.20091
• Thompson, A. L., Méndez, M. A., Borja, J. B., Adair, L. S., Zimmer, C. R., & Bentley, M. E. (2009). Development and validation of the Infant Feeding Style Questionnaire. Appetite, 53(2), 210–221. https://doi.org/10.1016/j.appet.2009.06.010

13. Items of the Scale