Family Practice Vol. 19, No. 6, 698-702
© Oxford University Press 2002
Selections from Current Literature |
Attitudes and practices regarding the introduction of solid foods to infants
Department of Family Medicine, State University of New York at Stony Brook.
Lorraine Danowski, Department of Family Medicine, State University of New York at Stony Brook, Stony Brook, NY 11794–8461, USA; E-mail: Ldanowski{at}notes.cc.sunysb.edu
Danowski L and Gargiula L. Attitudes and practices regarding the introduction of solid foods to infants. Family Practice 2002; 19: 698–702.
Received 4 July 2002; Accepted 16 July 2002.
Introduction
Current recommendation regarding the introduction of solid foods is that it should be between four and six months of age. These recommendations are due to concern over infant food sensitivities, growth and development. Observational studies support the finding that early introduction of solid foods may result in a heavier child, but these results have not been duplicated by other researchers.1
The incidence of allergy is on the rise. This increase has highlighted the need for primary prevention and an interest in the role of early nutrition. Elimination of certain foods in the diet during pregnancy and lactation has been beneficial in cases of infants from atopic families.2,3 In at risk infants, maternal avoidance of allergenic foods during lactation, exclusive breast feeding for six months, use of extensive hydrolysate formula, if required and introduction to solids after four and preferably six months of age reduces the incidence of atopic syndromes.2
The issue over early introduction to solids and infant growth has been raised. In a study conducted by Mehta et al. no differences were found in body composition or growth between early and late introduction of solid foods. Early introduction of solids was between three and four months and late introduction of solids was at 6 months. Anthropometric measurements were obtained at three, six, or twelve months of age and showed no significant differences.1 Another study related early vigorous suckling with the possibility of long-term obesity in an infant at high risk.4
This article looks at current feeding practices of low income and middle/upper income mothers. Successful educational strategies to overcome pressure from multigenerational households to follow the current guidelines is discussed. An early work by Skinner and colleagues looks at feeding practices compared to the 1970s and 1980s in middle/upper income mothers with a higher educational level. Black and colleagues are mainly interested in the educational strategies that could effect change in the area of infant feeding using a videotape and mentorship model with low income families. Kannan, Carruth and Skinner investigated middle/upper socio-economic mothers of Anglo-American and Asian-Indian American populations and infant feeding practices. Despite change in socio-economic status of this population, family influence was overwhelming and was at opposition to current feeding practices. Anderson et al. reported on attitudes and beliefs which influence when solids are introduced. They found that most mothers felt that they were responding to cues from their infant and that current guidelines were not individualized.
Black MM, Siegel EH, Abel Y, Bentley ME. Home and videotape intervention delays early complementary feeding among adolescent mothers. Pediatrics 2001; 107: E67.
Summary.
Many families do not adhere to the recommendations supplied by the American Academy of Pediatrics, the special supplemental Nutrition Program for Women, Infants and Children and the World Health Organization that infants should be fed only breast milk or formula for the first four to six months of life. The following investigation was conducted to determine if previously used intervention methods, to modify parenting behaviours among adolescent mothers, would be effective in promoting the recommended feeding guidelines among first-time, black, low income, adolescent mothers.
Focus groups consisting of adolescent mothers regarded as successful based on parenting behaviour, academic performance and school citizenship were selected. These groups developed the messages that they felt were important to communicate to other mothers. Videotaping took place in homes, schools and day care centres. Adolescent mothers were featured with children, partners and mothers discussing care-giving issues and strategies to avoid mother–grandmother conflict.
One hundred and twenty-one adolescent mothers were enrolled in this study. Adolescent mothers lived with their mothers, and were free of chronic disease, less than 18 years of age at delivery, first-time mothers, black, and had a family income under 185% of the poverty level. The infants included were full term, weight appropriate for gestational age, born without chronic illness or congenital abnormalities. All mothers interested in entering the study were scheduled to receive a baseline home evaluation within three weeks of delivery. Mothers were than randomized into an intervention (58 participants) or control (63 participants) group. The intervention group received home visits every other week until the infant was 12 months old.
A three month follow-up by telephone or mail was conducted on both groups, which included completion of a food frequency questionnaire on infant’s dietary patterns. Based on questionnaire results mothers were classified into one of two groups: optimal feeders (breast milk, formula or water) and less optimal feeders (complementary foods juice, fruit, milk etc.). Thirty four per cent of the mothers were classified as optimal feeders and 66% were classified as less than optimal feeders. Bivariate comparisons revealed that mothers in the optimal feeders group had a younger child, an income above $20 000, were able to report accurate advice from WIC and be in the intervention group. The authors conclude that this type of intervention, although brief, was successful due to the fact that it specifically targets cultural barriers that may interfere with the mothers’ acceptance of established guidelines for feeding.
Comment. This article shows that changes in feeding behaviours are possible among first-time, black, adolescent mothers living in a multigenerational home. The intervention group was comprised of two basic components, a videotape that comprised 19 topics such as interpreting infant’s cues and mother–grandmother negotiation strategies and home-based visits using a mentorship model. Three distinct groups such as a control, home-based visit programme using a mentorship model or videotape viewing may answer the question of which had the most effectiveness. One third of the mothers or 34% were described as optimal feeders, providing only formula, breast milk or water to their infants. This value was raised to 39% when optimal feeders included a sugar and water mixture. A sugar and water mixture would provide little nutritional value and may be considered a complementary food by many. This study was reported after data collection at the three month point. Some optimal feeders may have introduced solids before the four month guideline which would change the percentages.
Kannan S, Carruth BA, Skinner J. Infant Feeding Practices of Anglo American and Asian Indian American Mothers. J Am Coll Nutr 1999; 18: 279–286.
Kannan et al. hypothesized that compared to Asian-Indian American mothers, Anglo-American mothers would have a greater incidence and duration of breast feeding, would delay the introduction of solid foods and would rely on professional sources of information regarding infant feeding practices. The Anglo-American (AA) and Asian-Indian American (AIA) population supplied fifty mother/infant pairs for this study. Eligibility criteria was defined as: primiparous, above 19 years of age, middle and upper socio-economic status and for the Asian-Indian American mothers a resident in the United States for greater than one year and less than eight years. Both infant groups had to be healthy, full term infants and weigh greater than 2500 grams at birth.
Modifications to a pre-existing questionnaire were used for data collection. At one, three, six, nine and twelve months of age, data on breast feeding practices, type and amount of formula, age of infant when supplemental foods and type were introduced, primary sources of information about infant feeding and weight, length and head circumference were recorded. At the one month interview, detailed instructions on recording infant intake were given. To encourage accurate results sample utensils such as jars, bottles and cups were provided.
Data included descriptive statistics, using means and frequencies for the number of mothers breast feeding at the time intervals noted, duration of breast feeding and the age of infant at introduction to formula or supplementary foods. Averages were calculated for the number of mothers using various sources of information at the one, three, six, nine and twelve month period. To calculate nutrient values for exclusively breast-fed infants, 750 ml/day was used as the standard. For formula-fed infants ounces per day were used in nutrient calculations. If an infant received formula and breast milk, the amount of formula was subtracted from the 750 ml standard. Supplemental food calculations and 750 ml of breast milk was used for infants who consumed both solids and breast milk.
Differences in the length of time AA mothers and AIA mothers breast-fed was significant. Anglo-American mothers breast-fed longer, with many stopping between six and nine months. The AIA mothers maximum decrease in breast feeding occurred between three and six months.
AIA mothers introduced supplementary foods earlier than AA mothers. Nine AIA mothers introduced rice and lentil-based food as the first supplementary foods. The AA mothers introduced rice cereal followed by oatmeal and mixed cereals most frequently in the first six months. At five months, all AIA infants received fruit as compared to AA mothers who introduced fruit at six months. Vegetables were offered to AIA infants by six months, whereas only 20 out of 25 AA mothers offered vegetables to their infants by six months. Meat and meat substitutes were introduced earlier in the AIA group. Most AIA mothers had introduced legumes to their infants by 3.5 months. AA mothers used pediatricians as their primary source of information related to infant feeding. AIA mothers reported grandmothers as their primary source regarding infant feeding practices. The AIA infants had significantly higher kcal and fat intakes than the AA infants for the duration of the study.
Comment. The author’s hypothesis that cultural differences play an important role in infant feeding practices is supported by the results of this study. Results may be affected by the small sample size, timing of relative visits, socio-economic status and length of residency in the United States of the AIA mothers.
Data collection limitations may affect the nutrient differences noted. Twenty-four hour recalls were used to determine nutrient intake and this method would not allow for individual variations that would occur on a day to day basis. Breast milk intake was the same for all infants and may not reflect individual habits of each infant involved in the study. Adjustments in breast milk intake was not made when solid foods were introduced and may impact on calories and protein consumed. This study showed significant differences in the AA and AIA mothers’ feeding practices.
Anderson A, Guthrie CA, Alder E, Forsyth S, Howie P, Williams F. Rattling the plate—reasons and rationales for early weaning. Health Educ Res 2001; 16: 471–479.
The goal of this study was to identify the cultural and social norms and attitudes which mothers felt influenced their decisions about weaning. The decision of when to introduce solids is complex. Understanding the decision-making process is an important step prior to designing an intervention strategy to affect change in behaviour.
Focus groups consisting of primiparous, multiparous and one mixed group took part in the discussions. Inclusion criteria was English speaking women without cognitive or mental disabilities, who had babies aged 8 to 18 weeks at the Forth Park Maternity hospital (UK). The aim was to include mothers from more deprived backgrounds. Parity was a key factor for placement of mothers in specific groups. The focus groups lasted about 1.5 hours. Participants were guided toward the research question being asked if it did not occur on its own. Initially the groups focused on infant growth and health which led into discussions of dietary, sleep and behaviour patterns and how the mothers perceived their interrelationships. The discussions were focused on food as opposed to breast or bottle feeding.
Five focus groups with a total of 29 participants were conducted. The mean age of the infants was 13+/–4.2 weeks. Ten of the participants reported the introduction of solid food to their infants at a mean age of 11.6 weeks. The groups indicated that the introduction of solids was felt to be cues from the infant. Some physical and chronological characteristics included age of four months, reaching a set weight or subjective size, teething, increased saliva production and constipation. Another vague rationale for introduction of solids related to perceptions of hunger mostly exhibited by "a hungry cry". Other signs of hunger were stated as the infant was looking at the food others were consuming, taking milk too quickly and looking for more milk, sucking air from the bottle when it was completed, needing to feed more frequently, "chewing hands", or changing sleeping patterns.
Participants responded to the question of how they felt when solids were first introduced by stating they were "proud" and felt it was "a big achievement for a baby to eat solids". The main reason solids were introduced was to "settle the baby". Participants felt reassured if the infant became content and did not suffer any ill effects from the solids. All participants were aware of the recommended guidelines regarding feeding but approximately half had or were planning to introduce solids before this time. Only one participant out of the 29 could state the health implications associated with early introduction of solids.
The lack of understanding about the current recommendations is complicated by the fact that partners and friends report being given solids before four months and are healthy. Guidelines prior to 1994 allowed for introduction of solids at three months of age and may make some feel that the guidelines are arbitrary. Many felt the guidelines were not individualized enough to allow for different growth rates.
Comment. The appropriate cues were provided to elicit responses needed to fulfil the study purpose. Careful attention was paid to avoid undue emphasis on the role of health professionals by having a psychology research assistant lead the groups.
Further education to this population is needed to allow the mothers to understand the basis of the guidelines. Participants were a convenient sample and not necessarily representative of the population as a whole. Multiparous women were included in the focus groups and may have influenced the primiparous mothers during the discussions, however only one group was mixed. Weaning needs to be clearly defined to aid investigators in determining who is following the guidelines. Additives to the bottle were considered "milk feeds" and not weaning by parents as opposed to health professionals who consider this weaning due to the immunological response.2
Skinner JD, Carruth BR, Houck K, Moran J, Coletta F, Cotter R, Ott D, McLeod M. Transitions in Infant Feeding During the First Year of Life. J Am Coll Nutr 1997; 16: 209–215.
This study was designed to answer the question of what are the current patterns of weaning and transitioning of infants to complementary foods among white, middle/ upper income, educated mothers. Ninety-eight mother/ infant pairs were recruited for this longitudinal study. Mothers were interviewed four to five times during the infant’s first year of life. Infant/mother pairs were included if infants were full term, healthy and from middle/ upper socio-economic status. Each interview included questions regarding type of milk or formula the infant was receiving and whether or not six categories of baby or table food had been added to the diet. Once a positive response to solids was elicited the question was not asked again.
Means, frequencies and standard deviations were calculated for demographic data and ages of when each food category was introduced into the infant’s diet. Greater than 60% of both mothers and fathers had at least one college degree. Forty-eight per cent of the mothers were primiparous and the rest were multiparous. Mean heights, weights, and head circumferences were near the 50th percentile at all data points.
Eighty-three per cent of the mothers breast feed their infants initially and over 60% were breast feeding at least partially by two months. The mean age for the addition of cereal was 3.8 months. Fruit, juice and vegetables were added at mean ages of approximately five months. Cereal was the predominate first solid food followed by juice and a cereal and juice combination. Eighteen infants were given cereal on a regular basis by two months of age and 16 infants ate fruit by three months. These results show a wide range of variability. Meat and other table foods followed a different pattern of introduction.
The mode of feeding appeared to be the most important variable for predicting the age of adding cereal to the infant’s diet. Those mothers who used formula exclusively added cereal at a mean of 3.2 months. Breast-fed and combination breast/formula-fed infants received cereal at a mean age of 4.6 and 4.1 months respectively. Mode of feeding and education of the mother was significant. Mothers that used formula and did not hold four year degrees were the first to introduce cereal. First-time mothers added cereal earlier than did mothers with three or greater children. Breast-fed infants were introduced to cereal earlier with each child as opposed to formula-fed and breast/formula-fed infants. Physician recommendations regarding when to introduce solids was an important influence in this study. Mothers returning to work added cereal earlier than those not employed (mean of 3.7 as opposed to 4.2 months respectively). Thirty-one per cent of the mothers added cereal to the bottle, which is not medically indicated except under certain circumstances. The reasons that the mothers provided for this practice was to help alleviate hunger, avoid too frequent feedings and helping the baby sleep through the night. These mothers added cereal to the diet earlier than mothers who did not put cereal in the bottle.
Comment. Information on the patterns of solid food introduction and attitudes about breast feeding was satisfied with this study. One comment about results that is not clear is at what point in time the cereal was added to the bottle and if this was included as introduction to solid foods. The reasons for avoiding this practice need to be addressed with mothers during pregnancy to assure compliance.
The mother/infant pairs may not be representative of the population, as these mothers were higher socioeconomic status. Education was found to be a significant factor contributing to the introduction of solids. A lower socio-economic group may not have the benefit of the same educational opportunities. As with the preceding studies, cultural influences impact on the appropriate age to wean infants onto solid foods.
Conclusions
The literature supports introducing solid foods at four to six months and in certain circumstances, where allergy is a concern, after six months. Despite these guidelines, mothers continue to introduce solid foods early to satisfy what are perceived to be hunger cues. The first study was successful, as the optimal feeders were four times more likely to be in the intervention group. Despite this fact, 66% still introduced solids prior to the recommended guidelines. The success of this intervention was related to interpreting infant cues, negotiating with their own mothers to overcome cultural biases regarding feeding and the mentorship model in which the home visitor served as a role model. This may not be practical for many patients, but videotapes during waiting room visits and linking adolescent mothers with a role model may be feasible.
Cultural differences also contribute to feeding practices, as evidenced by the Asian Indian American mothers who introduced rice and lentils as the first supplementary foods. This occurred at three months of age during a weaning ceremony. The Asian Indian American population relied on the grandmothers for their information regarding infant feeding practices. Education for this population should be initiated early and reinforced at every visit by the health care professional.
When mothers were questioned about their attitudes toward solid food introduction, many responded to signs of changing sleep patterns or perceived hunger from the infant. This population was unable to clearly define the reasons for delaying the introduction of solids. Many also felt proud to have their infants eating solids. Although solids were introduced to settle or keep the infant satisfied, the myth that it would allow the baby to sleep through the night was not borne out.
Many consider cereal in the bottle or other additives as adhering to the current guidelines. This is not the case from the perspective of atopic syndrome prevention. Breast feeding and delay of solids for at least the first four months of life is recommended.5 In cases of gastroesophageal reflux, cereal is added during bottle feedings. This is not recommended as standard practice.
In the last study 18 out of 98 the mother infant pairs were initiated onto solids at two months of age and another 16 by three months of age. Physicians did influence the introduction of solids in this study and play a key role in the decision-making process. Still in many instances these guidelines were not followed.
Decisions regarding breast-feeding are made prior to conception and support population–based education aimed at women in child bearing years as well as patient instruction early in pregnancy.6 Information in the form of bulletins, videos or leaflets in waiting areas is needed to explain the rationale and refute cultural practices. Pregnancy is a time when many women will take the time to read and investigate what is best for them and their baby. We as health professionals, should utilize this time to educate this population.
References
1 Metha K, Specker B, Bartholmey S, Giddens J, Ho M. Trial on Timing of Introduction to Solids and Food Type on Infant Growth. Pediatrics 1998; 102: 569–573.
2 Hasad S. Food Allergen Avoidance in Primary Prevention of Food Allergy. Allergy 2001; 56 (Suppl 67): 113–116.
3 Hampton S. Prematurity, Immune Function and Infant Feeding Practices. Proceedings of Nutrition Society 1999; 58: 75–78.
4 Agras W, Kraemer H, Berkowitz R, Hammer L. Influence of Early Feeding Style on Adiposity at 6 Years of Age. J of Pediatrics 1990; 116: 805–809.
5 Duchin K, Thorell L. Nucleotide and Polyamine Levels in Colostrum and Mature Milk in Relation to Maternal Atopy and Atopic Development in the Children. Acta Paediatr 1999; 88: 1338–1343.[Web of Science][Medline]
6 Skinner J, Carruth B, Houck K et al. J Amer Coll Nutr 1997; 16(3): 209–215.[Abstract]
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||