<clinical_study>
  <!-- This xml conforms to an XML Schema at:
    https://clinicaltrials.gov/ct2/html/images/info/public.xsd -->
  <required_header>
    <download_date>ClinicalTrials.gov processed this data on September 20, 2023</download_date>
    <link_text>Link to the current ClinicalTrials.gov record.</link_text>
    <url>https://clinicaltrials.gov/ct2/show/NCT04477941</url>
  </required_header>
  <id_info>
    <org_study_id>1000058039</org_study_id>
    <nct_id>NCT04477941</nct_id>
  </id_info>
  <brief_title>Systematic Review of Parents' Stress and Feeding Styles and Practices</brief_title>
  <official_title>The Association Between Parents' Stress and Feeding Styles and Practices: Systematic Review and Meta-analysis of Observational Studies</official_title>
  <sponsors>
    <lead_sponsor>
      <agency>Mathilda Vandenheuvel</agency>
      <agency_class>Other</agency_class>
    </lead_sponsor>
    <collaborator>
      <agency>University of Toronto</agency>
      <agency_class>Other</agency_class>
    </collaborator>
  </sponsors>
  <source>The Hospital for Sick Children</source>
  <oversight_info>
    <has_dmc>No</has_dmc>
    <is_fda_regulated_drug>No</is_fda_regulated_drug>
    <is_fda_regulated_device>No</is_fda_regulated_device>
  </oversight_info>
  <brief_summary>
    <textblock>
      Parents' mental health contributes to their feeding practices how they perceive and respond&#xD;
      to their children's behavior. Suboptimal feeding practices may promote dysfunctional eating&#xD;
      behaviours in children and contribute to children's weigh. The purpose of this review is to&#xD;
      identify existing literature on the association between parents' stress and their feeding&#xD;
      styles and practices&#xD;
    </textblock>
  </brief_summary>
  <detailed_description>
    <textblock>
      Background:&#xD;
&#xD;
      Feeding is a central aspect of parenting that involves interactions between parents and their&#xD;
      children. Those feeding interaction influence children's eating behaviors during a sensitive&#xD;
      period of growth and cognitive development. Parents' feeding styles and parents' feeding&#xD;
      practices are terms that have been used to describe feeding interactions between parents and&#xD;
      their children. Previous research have found that parents' feeding styles and feeding&#xD;
      practices are associated with different children's outcomes (e.g. growth, weight).Throughout&#xD;
      literature, the terms of parents' feeding styles and feeding practices have been used&#xD;
      interchangeably.&#xD;
&#xD;
      Parenting styles can be defined as attitudes or an emotional climate that characterizes the&#xD;
      parents' approach and interaction with their children across different domains of parenting.&#xD;
      Those domains can be characterized based on demandingness (defined as behavioral control over&#xD;
      the child) and responsiveness (defined as warmth and supportiveness for the child). Based on&#xD;
      those domains there are four parenting styles: authoritative, authoritarian, indulgent and&#xD;
      neglectful. An authoritative parenting style can be characterized as a style associated with&#xD;
      a high level of responsiveness and demandingness to the child. As for the authoritarian&#xD;
      parenting style can be defined as style with low responsiveness and high demandingness.&#xD;
      Whereas the indulgent parenting style can be characterized as a style with high&#xD;
      responsiveness and engagement with the child but with low demandingness. Finally, an&#xD;
      uninvolved parenting style is defined as a style with both low responsiveness and low&#xD;
      demandingness.&#xD;
&#xD;
      Parenting feeding styles can be defined as attitudes or an emotional climate that&#xD;
      characterizes the parents' approach with their children during feeding interaction. Feeding&#xD;
      styles are a sub-category of parenting styles with similar domains of responsiveness and&#xD;
      demandingness applied within a feeding context. For instance, an authoritarian feeding style&#xD;
      is where a parent supports and encourages their child eating with directives and rules&#xD;
      regardless to the child's preferences, whereas a parent with an authoritative feeding style a&#xD;
      parent encourages eating with a non-directive approach and is responsive to the child's&#xD;
      preferences and needs.&#xD;
&#xD;
      Parents' feeding practices concept refers to the strategies and techniques parents may employ&#xD;
      to maintain or control the feeding context such as when, what or how much their children eat.&#xD;
      Feeding practices are intended specific behaviors parents use to influence their children's&#xD;
      eating and differ based on parents' perceptions and beliefs of how to achieve optimal growth&#xD;
      for their children. For instance, a parent could limit access to certain food types to&#xD;
      control his/her child's weight, or force feed the child to increase his/her weight. Different&#xD;
      feeding practices have been discussed in literature such as restriction of certain food&#xD;
      types, pressuring to eat, or using food as a reward. Feeding practices have been associated&#xD;
      with weight and eating behaviors in children. Ventura and Birch argue that parental feeding&#xD;
      practices are a response to a child's behaviour rather than a parental trait.Moreover,&#xD;
      parental feeding style can be consistent, or found within a parent, but parental feeding&#xD;
      practices can be different depending on different factors such as a child's weight and&#xD;
      temperament.&#xD;
&#xD;
      Parents' mental health influence parents' feeding style and practices.The World Health&#xD;
      Organization (WHO) defines mental health as &quot;a state of well-being in which individual&#xD;
      realizes his or her own abilities, can cope with the normal stresses of life, can work&#xD;
      productively and fruitfully, and is able to make a contribution to his or her community&quot;.&#xD;
      Caregivers' mental health problems are considered to be a major public health challenge&#xD;
      worldwide. Parents' mental health, such as stress and depression, influences how they&#xD;
      perceive their children's behavior, as well as how they interpret and respond to their child&#xD;
      behaviors. In a study by Hurley et al, they found that mothers who experienced more symptoms&#xD;
      of stress, depression and anxiety were more likely to engage in non-responsive feeding&#xD;
      practices. In another study by Swyden et al, they found an association between mothers with a&#xD;
      high level of stress and restrictive feeding practices such as restricting the amount and&#xD;
      type of food been consumed.&#xD;
&#xD;
      Stress in general can be characterized as the ability to cope with challenges, or an&#xD;
      emotional or behavioral response an individual may experience toward an unpleasant event.&#xD;
      While parenting stress can be conceptualized as psychological distress experienced by parents&#xD;
      as a response to their efforts to meet parenting demands. Different studies have examined&#xD;
      parents' stress (either general stress or parenting stress) in association with feeding style&#xD;
      and practices of parents, child weight and eating behaviours. For instant, in a&#xD;
      cross-sectional study, mothers who reported a high level of stress symptoms were more likely&#xD;
      to engage in forceful, controlling and restriction feeding practices. In another&#xD;
      cross-sectional study by Hughes et al, the relationship between parental emotional distress&#xD;
      and feeding style in low-income parents with preschool children was examined. They reported&#xD;
      that parents with uninvolved feeding style had a high level of parenting stress compared to&#xD;
      parents with other feeding styles: authoritative- authoritarian and indulgent. These results&#xD;
      support the claim that there is a relationship between parents' stress and their feeding&#xD;
      styles and/or practices.&#xD;
&#xD;
      Objective:&#xD;
&#xD;
      The primary objective of this systematic review and met-analysis is to summarize existing&#xD;
      literature on the association between parents' stress (both parenting and general stress) and&#xD;
      parents' feeding styles and practices (both parents' emotional climate and strategies applied&#xD;
      in the context of feeding).&#xD;
&#xD;
      Design:&#xD;
&#xD;
      This systematic review and meta-analysis will be conducted according to the Cochran Handbook&#xD;
      for Systematic Reviews of Interventions and the results will be reported according to&#xD;
      Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines and Preferred&#xD;
      Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines.&#xD;
&#xD;
      Data Sources:&#xD;
&#xD;
      The investigators will search the following databases: MEDLINE, EMBASE, and PSYCHINFO&#xD;
      (accessed via Ovid), CINAHL (accessed via Ebsco). The authors will apply appropriate search&#xD;
      strategy through database. Searches will be supplemented with manual searches of references&#xD;
      of included publications.&#xD;
&#xD;
      Data Extraction:&#xD;
&#xD;
      Two or more investigators will independently extract relevant data and assess risk of bias.&#xD;
      First, title and abstract of identified studies will be screened for eligibility. Second,&#xD;
      full texts will be examined in detail based on eligibility criteria outlined above. Third,&#xD;
      references of all considered articles will be screened for any potentially eligible studies&#xD;
      that were not captured in the search strategy. Any disagreement between the reviewers will be&#xD;
      resolved by author (MV). For missing data, authors of primary publication will be contacted.&#xD;
      Risk of bias for observational studies will be assessed using the Newcastle Ottawa Scale. As&#xD;
      for cross-sectional studies, risk of bias will be assessed using the National Institutes of&#xD;
      Health &quot;Quality assessment tool for observational cohort and cross-sectional studies&quot;.&#xD;
&#xD;
      Data synthesis and statistical analysis:&#xD;
&#xD;
      The extracted data from included studies (e.g., participants' characteristics, exposure,&#xD;
      outcomes, results and direction of association) will be used to build an evidence table.&#xD;
      Also, if sufficient studies are identified and variability is low, data from included studies&#xD;
      will be pooled using the generic inverse variance method. A random-effect model will be used&#xD;
      to determine the association between parents' stress and their feeding styles.This will be&#xD;
      done under the assumption that the true effects are normally distributed. Fixed-effects&#xD;
      models will be used only where there are &lt;5 included associations.&#xD;
&#xD;
      Assessment of heterogeneity:&#xD;
&#xD;
      The investigators will evaluate heterogeneity by estimating the variance between studies&#xD;
      using Cochran Q statistic and quantified by the I2 statistic. The Cochran's Q test is&#xD;
      obtained by the weighted sum of the squared differences of the observed effect in each study&#xD;
      minus the fixed summary effect. The I2 statistic describes the percentage of variability in&#xD;
      the effect estimate that is not due to chance and (I2 &gt;= 50%) indicates a substantial&#xD;
      heterogeneity with a p-value of &lt;0.1 as a statistically significant level. To explore sources&#xD;
      of heterogeneity, investigators will conduct sensitivity analyses in which each study is&#xD;
      systematically removed. If &gt;=10 studies are available, potential sources of heterogeneity by&#xD;
      a priori subgroup analyses will be explored. The investigators will conduct subgroup analyses&#xD;
      that will depend on identified studies; determined by study design (prospective or&#xD;
      retrospective), follow-up time, setting (developed or developing countries),&#xD;
      socio-demographic characteristics, sample size and adjustment for confounding variables&#xD;
      (i.e., gender, education and history of mental health). If &gt;=10 studies are available,&#xD;
      publication bias will be assessed by an inspection of funnel plots and tested using the Egger&#xD;
      and Begg test. If publication bias is suspected, the Duval and Tweedie trim and fill method&#xD;
      will be applied to adjust for funnel plot asymmetry by imputing missing study data.&#xD;
&#xD;
      Evidence Assessment:&#xD;
&#xD;
      Two reviewers will independently assess the quality and strength of included studies using&#xD;
      the Grading of Recommendation Assessment, Development and Evaluation (GRADE) system.&#xD;
&#xD;
      Observation studies start at low-quality evidence and can be downgraded or upgraded based on&#xD;
      the following criteria:&#xD;
&#xD;
        1. Criteria to downgrade evidence: risk of bias, inconsistency, indirectness, imprecision&#xD;
           and publication bias.&#xD;
&#xD;
        2. Criteria to upgrade evidence: large effect size, attenuation by all plausible&#xD;
           confounding effects and dose-response gradient.&#xD;
&#xD;
      Differences will be reconciled by consensus.&#xD;
    </textblock>
  </detailed_description>
  <overall_status>Completed</overall_status>
  <start_date type="Actual">June 30, 2020</start_date>
  <completion_date type="Actual">January 30, 2022</completion_date>
  <primary_completion_date type="Actual">December 30, 2021</primary_completion_date>
  <study_type>Observational</study_type>
  <has_expanded_access>No</has_expanded_access>
  <study_design_info>
    <observational_model>Other</observational_model>
    <time_perspective>Other</time_perspective>
  </study_design_info>
  <primary_outcome>
    <measure>the correlation between parents' stress and their feeding styles and practices</measure>
    <time_frame>follow up, up to 20 years</time_frame>
    <description>The difference in feeding style and practices in different levels of parents' stress expressed in mean difference or standardized mean difference (if different assessment tools were used in included studies)</description>
  </primary_outcome>
  <enrollment type="Actual">1</enrollment>
  <condition>Parent-Child Relations</condition>
  <condition>Stress</condition>
  <condition>Feeding Behavior</condition>
  <eligibility>
    <study_pop>
      <textblock>
        Parents of children (birth- 5 years)&#xD;
      </textblock>
    </study_pop>
    <sampling_method>Probability Sample</sampling_method>
    <criteria>
      <textblock>
        Inclusion Criteria:&#xD;
&#xD;
          -  Measurement of Feeding styles and/ or practices measurement (self - report assessment&#xD;
             and / or observational assessment)&#xD;
&#xD;
          -  Measurement of parent's stress (using assessment tools for stress in the study)&#xD;
&#xD;
          -  Observational design, (prospective and retrospective) with no follow-up time&#xD;
             restrictions&#xD;
&#xD;
          -  Cross-sectional design&#xD;
&#xD;
          -  Breastfeeding and complementary feeding studies&#xD;
&#xD;
        Exclusion Criteria:&#xD;
&#xD;
          -  Animal studies&#xD;
&#xD;
          -  Review studies&#xD;
&#xD;
          -  Post-partum depression&#xD;
      </textblock>
    </criteria>
    <gender>All</gender>
    <minimum_age>0 Years</minimum_age>
    <maximum_age>5 Years</maximum_age>
    <healthy_volunteers>No</healthy_volunteers>
  </eligibility>
  <location>
    <facility>
      <name>The Hospital for Sick Children</name>
      <address>
        <city>Toronto</city>
        <state>Ontario</state>
        <zip>M5G 1X8</zip>
        <country>Canada</country>
      </address>
    </facility>
  </location>
  <location_countries>
    <country>Canada</country>
  </location_countries>
  <reference>
    <citation>Nordang S, Shoo T, Holmboe-Ottesen G, Kinabo J, Wandel M. Women's work in farming, child feeding practices and nutritional status among under-five children in rural Rukwa, Tanzania. Br J Nutr. 2015 Nov 28;114(10):1594-603. doi: 10.1017/S0007114515003116. Epub 2015 Oct 5.</citation>
    <PMID>26435007</PMID>
  </reference>
  <reference>
    <citation>Shloim N, Edelson LR, Martin N, Hetherington MM. Parenting Styles, Feeding Styles, Feeding Practices, and Weight Status in 4-12 Year-Old Children: A Systematic Review of the Literature. Front Psychol. 2015 Dec 14;6:1849. doi: 10.3389/fpsyg.2015.01849. eCollection 2015.</citation>
    <PMID>26696920</PMID>
  </reference>
  <reference>
    <citation>Blissett J. Relationships between parenting style, feeding style and feeding practices and fruit and vegetable consumption in early childhood. Appetite. 2011 Dec;57(3):826-31. doi: 10.1016/j.appet.2011.05.318. Epub 2011 May 27.</citation>
    <PMID>21651932</PMID>
  </reference>
  <reference>
    <citation>Ventura AK, Birch LL. Does parenting affect children's eating and weight status? Int J Behav Nutr Phys Act. 2008 Mar 17;5:15. doi: 10.1186/1479-5868-5-15.</citation>
    <PMID>18346282</PMID>
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    <citation>Faith MS, Scanlon KS, Birch LL, Francis LA, Sherry B. Parent-child feeding strategies and their relationships to child eating and weight status. Obes Res. 2004 Nov;12(11):1711-22. doi: 10.1038/oby.2004.212.</citation>
    <PMID>15601964</PMID>
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  <reference>
    <citation>Thompson AL, Adair LS, Bentley ME. Pressuring and restrictive feeding styles influence infant feeding and size among a low-income African-American sample. Obesity (Silver Spring). 2013 Mar;21(3):562-71. doi: 10.1002/oby.20091.</citation>
    <PMID>23592664</PMID>
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    <citation>p6rwood RL, Schoelmerich A, Schulze PA, Gonzalez Z. Cultural differences in maternal beliefs and behaviors: a study of middle-class Anglo and Puerto Rican mother-infant pairs in four everyday situations. Child Dev. 1999 Jul-Aug;70(4):1005-16. doi: 10.1111/1467-8624.00073.</citation>
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    <citation>Galderisi S, Heinz A, Kastrup M, Beezhold J, Sartorius N. Toward a new definition of mental health. World Psychiatry. 2015 Jun;14(2):231-3. doi: 10.1002/wps.20231. No abstract available.</citation>
    <PMID>26043341</PMID>
  </reference>
  <reference>
    <citation>Hurley KM, Black MM, Papas MA, Caulfield LE. Maternal symptoms of stress, depression, and anxiety are related to nonresponsive feeding styles in a statewide sample of WIC participants. J Nutr. 2008 Apr;138(4):799-805. doi: 10.1093/jn/138.4.799. Erratum In: J Nutr. 2008 Oct;138(10):1982. Caufield, Laura E [corrected to Caulfield, Laura E].</citation>
    <PMID>18356338</PMID>
  </reference>
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    <citation>Swyden K, Sisson SB, Morris AS, Lora K, Weedn AE, Copeland KA, DeGrace B. Association Between Maternal Stress, Work Status, Concern About Child Weight, and Restrictive Feeding Practices in Preschool Children. Matern Child Health J. 2017 Jun;21(6):1349-1357. doi: 10.1007/s10995-016-2239-y.</citation>
    <PMID>28138826</PMID>
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    <citation>Hackie M, Bowles CL. Maternal perception of their overweight children. Public Health Nurs. 2007 Nov-Dec;24(6):538-46. doi: 10.1111/j.1525-1446.2007.00666.x.</citation>
    <PMID>17973731</PMID>
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    <citation>Barroso NE, Hungerford GM, Garcia D, Graziano PA, Bagner DM. Psychometric properties of the Parenting Stress Index-Short Form (PSI-SF) in a high-risk sample of mothers and their infants. Psychol Assess. 2016 Oct;28(10):1331-1335. doi: 10.1037/pas0000257. Epub 2015 Nov 23.</citation>
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    <citation>Hughes SO, Power TG, Liu Y, Sharp C, Nicklas TA. Parent emotional distress and feeding styles in low-income families. The role of parent depression and parenting stress. Appetite. 2015 Sep;92:337-42. doi: 10.1016/j.appet.2015.06.002. Epub 2015 Jun 4.</citation>
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    <citation>Bennett IM, Schott W, Krutikova S, Behrman JR. Maternal mental health, and child growth and development, in four low-income and middle-income countries. J Epidemiol Community Health. 2016 Feb;70(2):168-73. doi: 10.1136/jech-2014-205311. Epub 2015 Sep 10.</citation>
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  <verification_date>June 2022</verification_date>
  <study_first_submitted>July 4, 2020</study_first_submitted>
  <study_first_submitted_qc>July 17, 2020</study_first_submitted_qc>
  <study_first_posted type="Actual">July 20, 2020</study_first_posted>
  <last_update_submitted>June 2, 2022</last_update_submitted>
  <last_update_submitted_qc>June 2, 2022</last_update_submitted_qc>
  <last_update_posted type="Actual">June 3, 2022</last_update_posted>
  <responsible_party>
    <responsible_party_type>Sponsor-Investigator</responsible_party_type>
    <investigator_affiliation>The Hospital for Sick Children</investigator_affiliation>
    <investigator_full_name>Mathilda Vandenheuvel</investigator_full_name>
    <investigator_title>Staff physician</investigator_title>
  </responsible_party>
  <!-- Results have not yet been posted for this study                                          -->
</clinical_study>


download date: ClinicalTrials.gov processed this data on September 20, 2023
link text: Link to the current ClinicalTrials.gov record.
url: https://clinicaltrials.gov/ct2/show/NCT04477941
org study id: 1000058039
nct id: NCT04477941
lead sponsor: 
collaborator: 
has dmc: No
is fda regulated drug: No
is fda regulated device: No
Parents' mental health contributes to their feeding practices how they perceive and respond
      to their children's behavior. Suboptimal feeding practices may promote dysfunctional eating
      behaviours in children and contribute to children's weigh. The purpose of this review is to
      identify existing literature on the association between parents' stress and their feeding
      styles and practices
Background:

      Feeding is a central aspect of parenting that involves interactions between parents and their
      children. Those feeding interaction influence children's eating behaviors during a sensitive
      period of growth and cognitive development. Parents' feeding styles and parents' feeding
      practices are terms that have been used to describe feeding interactions between parents and
      their children. Previous research have found that parents' feeding styles and feeding
      practices are associated with different children's outcomes (e.g. growth, weight).Throughout
      literature, the terms of parents' feeding styles and feeding practices have been used
      interchangeably.

      Parenting styles can be defined as attitudes or an emotional climate that characterizes the
      parents' approach and interaction with their children across different domains of parenting.
      Those domains can be characterized based on demandingness (defined as behavioral control over
      the child) and responsiveness (defined as warmth and supportiveness for the child). Based on
      those domains there are four parenting styles: authoritative, authoritarian, indulgent and
      neglectful. An authoritative parenting style can be characterized as a style associated with
      a high level of responsiveness and demandingness to the child. As for the authoritarian
      parenting style can be defined as style with low responsiveness and high demandingness.
      Whereas the indulgent parenting style can be characterized as a style with high
      responsiveness and engagement with the child but with low demandingness. Finally, an
      uninvolved parenting style is defined as a style with both low responsiveness and low
      demandingness.

      Parenting feeding styles can be defined as attitudes or an emotional climate that
      characterizes the parents' approach with their children during feeding interaction. Feeding
      styles are a sub-category of parenting styles with similar domains of responsiveness and
      demandingness applied within a feeding context. For instance, an authoritarian feeding style
      is where a parent supports and encourages their child eating with directives and rules
      regardless to the child's preferences, whereas a parent with an authoritative feeding style a
      parent encourages eating with a non-directive approach and is responsive to the child's
      preferences and needs.

      Parents' feeding practices concept refers to the strategies and techniques parents may employ
      to maintain or control the feeding context such as when, what or how much their children eat.
      Feeding practices are intended specific behaviors parents use to influence their children's
      eating and differ based on parents' perceptions and beliefs of how to achieve optimal growth
      for their children. For instance, a parent could limit access to certain food types to
      control his/her child's weight, or force feed the child to increase his/her weight. Different
      feeding practices have been discussed in literature such as restriction of certain food
      types, pressuring to eat, or using food as a reward. Feeding practices have been associated
      with weight and eating behaviors in children. Ventura and Birch argue that parental feeding
      practices are a response to a child's behaviour rather than a parental trait.Moreover,
      parental feeding style can be consistent, or found within a parent, but parental feeding
      practices can be different depending on different factors such as a child's weight and
      temperament.

      Parents' mental health influence parents' feeding style and practices.The World Health
      Organization (WHO) defines mental health as "a state of well-being in which individual
      realizes his or her own abilities, can cope with the normal stresses of life, can work
      productively and fruitfully, and is able to make a contribution to his or her community".
      Caregivers' mental health problems are considered to be a major public health challenge
      worldwide. Parents' mental health, such as stress and depression, influences how they
      perceive their children's behavior, as well as how they interpret and respond to their child
      behaviors. In a study by Hurley et al, they found that mothers who experienced more symptoms
      of stress, depression and anxiety were more likely to engage in non-responsive feeding
      practices. In another study by Swyden et al, they found an association between mothers with a
      high level of stress and restrictive feeding practices such as restricting the amount and
      type of food been consumed.

      Stress in general can be characterized as the ability to cope with challenges, or an
      emotional or behavioral response an individual may experience toward an unpleasant event.
      While parenting stress can be conceptualized as psychological distress experienced by parents
      as a response to their efforts to meet parenting demands. Different studies have examined
      parents' stress (either general stress or parenting stress) in association with feeding style
      and practices of parents, child weight and eating behaviours. For instant, in a
      cross-sectional study, mothers who reported a high level of stress symptoms were more likely
      to engage in forceful, controlling and restriction feeding practices. In another
      cross-sectional study by Hughes et al, the relationship between parental emotional distress
      and feeding style in low-income parents with preschool children was examined. They reported
      that parents with uninvolved feeding style had a high level of parenting stress compared to
      parents with other feeding styles: authoritative- authoritarian and indulgent. These results
      support the claim that there is a relationship between parents' stress and their feeding
      styles and/or practices.

      Objective:

      The primary objective of this systematic review and met-analysis is to summarize existing
      literature on the association between parents' stress (both parenting and general stress) and
      parents' feeding styles and practices (both parents' emotional climate and strategies applied
      in the context of feeding).

      Design:

      This systematic review and meta-analysis will be conducted according to the Cochran Handbook
      for Systematic Reviews of Interventions and the results will be reported according to
      Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines and Preferred
      Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

      Data Sources:

      The investigators will search the following databases: MEDLINE, EMBASE, and PSYCHINFO
      (accessed via Ovid), CINAHL (accessed via Ebsco). The authors will apply appropriate search
      strategy through database. Searches will be supplemented with manual searches of references
      of included publications.

      Data Extraction:

      Two or more investigators will independently extract relevant data and assess risk of bias.
      First, title and abstract of identified studies will be screened for eligibility. Second,
      full texts will be examined in detail based on eligibility criteria outlined above. Third,
      references of all considered articles will be screened for any potentially eligible studies
      that were not captured in the search strategy. Any disagreement between the reviewers will be
      resolved by author (MV). For missing data, authors of primary publication will be contacted.
      Risk of bias for observational studies will be assessed using the Newcastle Ottawa Scale. As
      for cross-sectional studies, risk of bias will be assessed using the National Institutes of
      Health "Quality assessment tool for observational cohort and cross-sectional studies".

      Data synthesis and statistical analysis:

      The extracted data from included studies (e.g., participants' characteristics, exposure,
      outcomes, results and direction of association) will be used to build an evidence table.
      Also, if sufficient studies are identified and variability is low, data from included studies
      will be pooled using the generic inverse variance method. A random-effect model will be used
      to determine the association between parents' stress and their feeding styles.This will be
      done under the assumption that the true effects are normally distributed. Fixed-effects
      models will be used only where there are <5 included associations.

      Assessment of heterogeneity:

      The investigators will evaluate heterogeneity by estimating the variance between studies
      using Cochran Q statistic and quantified by the I2 statistic. The Cochran's Q test is
      obtained by the weighted sum of the squared differences of the observed effect in each study
      minus the fixed summary effect. The I2 statistic describes the percentage of variability in
      the effect estimate that is not due to chance and (I2 >= 50%) indicates a substantial
      heterogeneity with a p-value of <0.1 as a statistically significant level. To explore sources
      of heterogeneity, investigators will conduct sensitivity analyses in which each study is
      systematically removed. If >=10 studies are available, potential sources of heterogeneity by
      a priori subgroup analyses will be explored. The investigators will conduct subgroup analyses
      that will depend on identified studies; determined by study design (prospective or
      retrospective), follow-up time, setting (developed or developing countries),
      socio-demographic characteristics, sample size and adjustment for confounding variables
      (i.e., gender, education and history of mental health). If >=10 studies are available,
      publication bias will be assessed by an inspection of funnel plots and tested using the Egger
      and Begg test. If publication bias is suspected, the Duval and Tweedie trim and fill method
      will be applied to adjust for funnel plot asymmetry by imputing missing study data.

      Evidence Assessment:

      Two reviewers will independently assess the quality and strength of included studies using
      the Grading of Recommendation Assessment, Development and Evaluation (GRADE) system.

      Observation studies start at low-quality evidence and can be downgraded or upgraded based on
      the following criteria:

        1. Criteria to downgrade evidence: risk of bias, inconsistency, indirectness, imprecision
           and publication bias.

        2. Criteria to upgrade evidence: large effect size, attenuation by all plausible
           confounding effects and dose-response gradient.

      Differences will be reconciled by consensus.
observational model: Other
time perspective: Other
measure: the correlation between parents' stress and their feeding styles and practices
time frame: follow up, up to 20 years
description: The difference in feeding style and practices in different levels of parents' stress expressed in mean difference or standardized mean difference (if different assessment tools were used in included studies)
study pop: 
sampling method: Probability Sample
criteria: 
gender: All
minimum age: 0 Years
maximum age: 5 Years
healthy volunteers: No
facility: 
country: Canada
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responsible party type: Sponsor-Investigator
investigator affiliation: The Hospital for Sick Children
investigator full name: Mathilda Vandenheuvel
investigator title: Staff physician