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Table 5 GRADE-CERQual assessment: confidence that relationships in the model are a reasonable representation of the phenomenon of interest

From: Childhood fussy/picky eating behaviours: a systematic review and synthesis of qualitative studies

Summary of Review Finding (Relationship in Fig. 2)Studies Contributing to Review FindingMethodological LimitationsaCoherencebAdequacycRelevancedCERQual AssessmenteExplanation of CERQual Assessment
Theme 1 & 2: Child characteristics (including fussy eating behaviours) and parent feeding practices
Parent feeding practices have an impact on child fussy eating behaviours (either by overcoming, or reinforcing behaviours).A, B, C, D, E, F, G, I, JNo or very minor concerns that all coded parentfeeding practices were adequately reported in Study B. However finding is reported across studies with diverse methods.Minor concerns due to some cases where parents do not effectively influence the child and the possible influence of other factors such as knowledge and self-efficacy (D, E, G).Minor concerns that although impact of parents on child behaviours are often assumed by authors, there was a lack of quotes illustrating direct effectiveness of parent feeding practices on child fussy eating behaviours (A, C, D, G, I).Minor concerns that this finding is specific to mothers. Some studies have a broader focus (e.g. on food preferences rather than fussy eating specifically). This finding was represented across diverse countries, contexts, income levels, ethnicities, and age-groups.Moderate confidence: It is likely that the review finding is a reasonable representation of the phenomenon.There are some minor concerns regarding some disconfirming cases, potential influence of other factors, the lack of examples illustrating the effectiveness of practices, and that this finding is specific to mothers. However this finding was reported across diverse contexts.
Child characteristics (including pickiness, weight and temperament) impact parents’ use of feeding practices.A, B, C, E, F, G, H, I, JNo or very minor concerns. This finding was reported across many studies with different data collection and analysis methods.Minor concerns that in some cases the relationship may be explained by other factors (such as concern and conflict) (A, B) and some disconfirming cases where parents do not feed siblings differently (J).Minor concerns regarding lack of specific examples/quotes in some studies (A, C, E, G, H).No or very minor concerns that this finding is specific to mothers. This finding was identified across diverse countries, contexts, income levels, ethnicities, and age-groups.Moderate confidence: It is likely that the review finding is a reasonable representation of the phenomenon.Despite minor concerns regarding some disconfirming cases, the potential influence of other factors, and lack of examples/quotes in some studies this finding was identified across many studies with diverse methods and contexts.
Theme 3: Fussy eating behaviours, parent feeding practices and emotional climate at mealtimes
Manifestations of fussy eating (such as limited variety or quantity of food, and gestures such as pushing the plate away) are directly related to negative parent emotions such as frustration and concern.A, C, D, H, IMinor concerns that focus groups in studies A, C, H may impact parents’ discussions regarding emotions and parents may provide more emotional accounts when calling a helpline (D).Minor concerns that fussy eating may not always contribute to negative emotions and may depend on other factors such as parent feeding practices and severity of fussy eating (H).Minor concerns regarding lack of quotes supporting this finding (C, H) and lack of explanation of disconfirming cases in which mealtime emotions were not impacted by fussy eating behaviours (I).No or very minor concerns. Finding may be specific to mothers. Studies focus on impact of fussy/picky eating and represent diverse countries, contexts, income levels, ethnicities, and age-groups.Moderate confidence: It is likely that the review finding is a reasonable representation of the phenomenon.Although there are some minor concerns regarding the impact of data collection methods on discussions of emotions, the potential influence of other factors, and a lack of supporting quotes in some studies, this finding was reported across diverse contexts.
Parent feeding practices relate to the emotional climate at mealtimes (for example pressure to eat may be associated with conflict).A, F, H, I, JNo or very minor concerns regarding use of focus groups (A, H) which may impact discussions about emotions.Minor concerns that this is an over simplified finding and the direction of influence is not clear in some examples (H), and there are some disconfirming cases (I).Minor concerns regarding richness of data contributing to this finding in some studies (A, H).Minor concerns that this finding is specific to mothers. This finding was identified across diverse countries, contexts, income levels, ethnicities and age-groups.Moderate confidence: It is likely that the review finding is a reasonable representation of the phenomenon.Despite minor concerns that this is an over-simplified finding, and thin data in two contributing studies this finding was identified across diverse contexts.
Emotional climate at mealtimes (such as concern, anxiety, conflict and stress) impacts parents’ choice of feeding practices (e.g. cooking alternative meals).B, C, D, F, H, I, JNo or very minor concerns (regarding influence of focus groups and calls to helpline on reporting emotions). However the finding was reported across studies with diverse methods.Minor concerns due to some disconfirming cases where parents are persistent in their practices and not influenced by conflict/emotions) (I, J).Minor concerns regarding lack of specific examples/quotes and reliance on author interpretations in some studies (D, H).Minor concerns that this finding may be specific to mothers however this finding was identified across diverse countries, contexts, income levels, ethnicities and age-groups.Moderate confidence: It is likely that the review finding is a reasonable representation of the phenomenon.Although there were some concerns regarding some disconfirming cases and lack of specific examples/quotes this finding was identified across diverse contexts.
Theme 4: Fussy eating behaviours, parent feeding beliefs and parent feeding practices
Manifestations of fussy eating relate to parent feeding beliefs (for example, if a child refuses mushy food, fussy eating may be attributed to sensory sensitivity, or if a parent is faced with a highly neophobic child, they may experience lower self-efficacy).A, D, E, H, INo or very minor concerns.Minor concerns that the direction of the relationship is not always clear and is not explicitly stated in some studies.Minor concerns regarding reliance on second and third order interpretations in some studies.No or very minor concerns that this finding is specific to mothers. These studies are relevant to this finding focusing on descriptions and attributions of fussy eating.Moderate confidence: It is likely that the review finding is a reasonable representation of the phenomenon of interest.There are minor concerns as this relationship is not explicitly stated in some studies and there is a reliance on second and third order interpretations.
Parent self-efficacy relates to parent feeding practices.B, C, E, F, I, JNo or very minor concerns that focus groups in studies B & C may impact discussions on self-efficacy.Minor concerns that the relationship could be explained by other factors (e.g. child’s response to foods).Minor concerns regarding adequacy of specific quotes illustrating this finding, and reliance on second order (author) and third order (reviewer) interpretations from studies E and F.Minor concerns that this finding is specific to mothers, and that only one study specifically focuses on self-efficacy.Moderate confidence: It is likely that the review finding is a reasonable representation of the phenomenon of interest.There are minor concerns that this finding is over simplified and also influenced by other factors. Only one study specifically focused on self-efficacy (E) so there is a reliance on second and third order interpretations.
Attributions (perceived influences) of fussy eating relates to parent feeding practices.A, E, FNo or very minor concerns.Minor concerns that this is an oversimplified finding as there as some disconfirming cases (E).Moderate concerns regarding reliance on second and third order interpretations with limited quotes clearly illustrating a link. There are a small number of studies contributing to this finding.Minor concerns that this finding is specific to mothers of pre-schoolers.Low confidence: It is possible that this review finding is a reasonable representation of the phenomenon of interest.There were some disconfirming cases, and a reliance on second and third order interpretations as well as a limited number of studies contributing to this finding.
Beliefs about hunger regulation relate to parent feeding practices. For example, parents who believe it is the parents’ responsibility to ensure their child eats (“you can’t let them starve”) may cook alternative meals. However, parents who believe it is the child’s responsibility to regulate their hunger levels (“they will eat when they are hungry”) are more likely to just cook a meal.A, B, D, G, I, JNo or very minor concerns.No or very minor concerns that different definitions of fussy eating in study I may impact the extent to which parents have to adapt a meal in order for their child to eat.Minor concerns regarding reliance on author interpretations (D) and the lack of specific examples/quotes in some studies (A, G).No or very minor concerns that this finding is specific to mothers.High confidence: It is highly likely that the review finding is a reasonable representation of the phenomenon.Although there were minor concerns regarding the data adequacy in some studies, and that this finding may be specific to mothers, this finding was reported across studies representing different countries, age groups, ethnicities, and income levels.
Theme 5: Parent awareness of food preference development and effective feeding practices: Possible associations with beliefs, practices and emotions
Parents’ lack of awareness of neophobia, food preference development and effective practices relates to their feeding beliefs, practices, and emotions.A, GMinor concerns that purposeful sampling (G) and narrow age range (1–2.5 years) may result in the selection of parents who are less aware of neophobia, food preference development and effective practices.Moderate concerns regarding potential for other factors to explain the relationship and insufficient data to fully explain this finding.Moderate concerns regarding richness and quantity of data to support this finding, as well as a limited number of studies contributing to this finding.Minor concerns that this finding may be specific to parents of young children, and only A study (G) specifically focused on parent awareness.Low confidence: It is possible that this review finding is a reasonable representation of the phenomenon of interest.There were moderate concerns regarding coherence and data adequacy. In addition this finding was only identified in studies with parents of young children so may not be generalizable to all parents.
  1. aMethodological limitations: Concerns about the design or conduct of primary studies that contribute evidence to an individual review finding; bCoherence: how clear and cogent the fit is between the data and a review finding; cAdequacy: The degree of richness and quantity of data supporting a review finding; dRelevance: Extent to which the body of evidence is applicable to the context specified in the review question; eCERQual assessment categories: high confidence, moderate confidence, low confidence, very low confidence (Lewin et al., 2018)