Healthy eating for infants–mothers'actions

Stordy BJ, Redfern AM, Morgan JB, Healthy eating for infants–mothers'actions. Acta Paediatr 1995;84:733-41. Stockholm. ISSN 0803-5253
The aim of this study was to analyse the nutrient composition, with respect to energy density, protein, fat, carbohydrate, non-starch polysaccharides and certain micronutrients, of home-prepared infant foods and to compare the nutrient composition with the draft European Commission directive for baby foods, the published nutrient content of manufactured baby foods, and with breast milk. Two hundred and sixty-five samples of home-prepared weaning foods for infants aged 3-12 months were collected and chemically analysed. Many of the food samples were low in energy, protein, fat, iron, calcium and zinc and high in non-starch polysaccharides and sodium. Home-prepared weaning foods have some shortcomings in terms of nutrient composition. Advice from health care professionals needs to focus on these areas at the same time as presenting the nutritional merits of manufactured baby foods. Baby food, infant feeding, infant food composition     

Differences in eating behaviour,well‐being and personality between mothers following baby‐led vs. traditional weaning styles

Baby‐led weaning, where infants self‐feed family foods in place of traditional spoon‐feeding of purees, is continuing to grow in popularity. Evidence is emerging which suggests that the method may promote healthier eating behaviour and weight gain in children, but the research is in its infancy. One issue is the self‐selecting nature of participants to the approach. Although those who follow a baby‐led approach are known to have a higher education and more professional occupation, little is known about wider maternal characteristics, which might affect either adoption of or outcomes of the method. The aim of this study was to explore differences in maternal characteristics between those adopting a baby‐led or traditional approach. Six hundred four mothers with an infant aged 6–12 months completed a questionnaire including a copy of the Dutch Eating Behaviour Questionnaire (DEBQ), Brief Symptom Inventory (BSI) (anxiety, obsessive–compulsive and depression scales) and Ten Item Personality Questionnaire (TIPQ) alongside details of weaning approach (baby‐led vs. traditional). Mothers who adopted a baby‐led weaning style scored significantly lower on restrained eating (DEBQ), anxiety and introversion (TIPQ) and anxiety and obsessive–compulsive symptoms (BSI). Mothers who currently adopt a baby‐led approach are therefore significantly different in personality, eating behaviour and well‐being characteristics compared with those adopting a traditional approach. These characteristics may affect likelihood of choosing a baby‐led approach or indirectly affect outcomes for infants weaned using the approach. Further research exploring baby‐led weaning in a wider population sample is needed.     

A comparison of infant and toddler feeding practices of mothers with and without histories of eating disorders

This preliminary study surveyed the feeding practices of mothers with eating disorder histories through evaluation of mothers' reported feeding styles, child diet composition and restrictive special approaches to feeding. For this non‐randomised cohort study, 25 mothers with eating disorder histories and 25 mothers with no history of an eating disorder with children ages 6–36 months were selected such that the groups were similar based on child age group and child sex. Mothers were compared on self‐reported feeding style using the Infant Feeding Styles Questionnaire and on child diet composition and special feeding approaches using a modified version of the Toddler Diet Questionnaire from the Women, Infants, and Children program. Mothers with eating disorder histories scored lower on the restrictive feeding style subscale than controls. No significant differences were detected between groups in child diet including the percentage of mothers who breastfed, duration of breastfeeding, age at solid food introduction, daily number of meals or snacks or daily frequency of consumption of fruits, vegetables or protein foods. Mothers with eating disorder histories were more likely to report taking a restrictive special approach to feeding such as limiting processed foods or feeding organic foods only. Although mothers with eating disorder histories may not differ greatly from control mothers in terms of child diet composition (smaller effects may not have been detected due to limited sample size), they may be more likely to take restrictive special approaches to feeding which mirror dietary rules common in individuals with eating disorders.     

A descriptive study investigating the use and nature of baby-led weaning in a UK sample of mothers

An alternative to traditional weaning methods known as baby-led weaning (BLW) appears to be emerging in the UK. This approach advocates bypassing typical weaning practices of spoon-feeding puréed foods or baby rice, encouraging instead the introduction of foods in their whole form to the infant from 6 months old. A key tenet of BLW is self-feeding. Anecdotally, the practice of BLW appears to be gaining in popularity. However, research evidence is scant, and little is known about the nature of BLW and the demography of those who utilize it. This study aimed to characterize a sample of women who have chosen to adopt the BLW method and to describe associated attitudes and behaviours. Six hundred and fifty five mothers with a child between 6 months and 12 months of age provided information about timing of weaning onset, use of spoon-feeding and purées, and experiences of weaning and meal times. Those participants who used a BLW method reported little use of spoon-feeding and purées and were more likely to have a higher education, higher occupation, be married and have breastfed their infant. BLW was associated with a later introduction of complementary foods, greater participation in meal times and exposure to family foods. Levels of anxiety about weaning and feeding were lower in mothers who adopted a BLW approach. These findings provide an insight into BLW practices and the characteristics of a small population of users.     

An online survey of knowledge of the weaning guidelines,advice from health visitors and other factors that influence weaning timing in UK mothers

The UK weaning guidelines recommend the introduction of solid food at or around 6 months. The evidence suggests that knowledge of the guidelines is high, although only a small minority of parents wait until 6 months to wean. The aim of this study was to assess understanding of the UK weaning guidelines in a sample of UK parents and investigate the associations of this understanding with weaning timing, and in comparison to other influencing factors. This study conducted an online survey of UK parents. Eligible participants had weaned a child since the introduction of the current guidelines. Of 3607 participants, 86% accurately understood the guidelines. Eighty‐seven per cent of health visitors were reported to have advised weaning at or around 6 months. Knowledge of the guidelines was associated with later weaning (independently of demographic factors) (P < 0.001) but did not ensure compliance: 80% of mothers who weaned before 24 weeks and 65% who weaned before 17 weeks were aware of the guidelines. Younger mothers (P < 0.001), those receiving benefits (P < 0.001), those educated only to 16 (P < 0.001) and minority ethnic groups (P < 0.001) had lower levels of awareness. Poor understanding of the guidelines was the most reliable predictor of early weaning (P = 0.021) together with young maternal age (P = 0.014). Following the baby‐led weaning approach was the most reliable predictor of those weaning at 26 weeks, together with the Internet being the most influential source of advice. Understanding of the current weaning guidelines is high and is a key independent predictor of weaning age in this population.     

Occurrence of diarrhoeal diseases in relation to infant feeding practices in a rural community in West Bengal,India

In a rural community-based prospective study, diarrhoea in relation to the feeding patterns of a cohort of infants was studied. A total of 148 infants between the ages of 0 and 2 months were enrolled and followed until the completion of 1 year of age. Survival analysis showed that by the fourth month of age exclusive breastfeeding dropped by 75%. The proportion of complementary breastfeeding increased from 18.6 to 52.9% during the same period and to 83.7% by the eighth month. This study clearly highlights the tendency for early switch over from exclusive breastfeeding to complementary breastfeeding. Early weaning was associated with an incidence rate ratio (IRR) of 3.02 (95% CI 1.043–8.802). The IRR of 3.02 and its confidence limits (1.043–8.02) suggest a significant protective effect of exclusive breastfeeding against diarrhoea in infants. The results of this study indicate that promotion of exclusive breastfeeding has a potential role to reduce the incidence of diarrhoea amongst infants. The findings of this study will be useful for Diarrhoeal Disease Control Programme in reducing diarrhoeal morbidity.     

UK mothers' experiences of bottle refusal by their breastfed baby

Little is known about bottle refusal by breastfed babies; however, an informal review of global online forums and social media suggested large numbers of mothers experiencing the scenario. This study aimed to explore UK mothers' experiences of bottle refusal by their breastfed baby in order to provide understanding of the scenario and enhance support for mothers experiencing it. A 22‐point online questionnaire was developed and completed by 841 UK mothers. Findings suggest that mothers introduced a bottle to their breastfed baby due to physical, psychological and socio‐cultural factors. Advice and support for mothers experiencing bottle refusal was not always helpful, and 27% of mothers reported bottle refusal as having a negative impact on their breastfeeding experience. When compared with eventual bottle acceptance, bottle refusal was significantly associated with previous experience of bottle refusal (p < .001), how frequently mothers intended to feed their baby by bottle and babies being younger at the first attempt to introduce a bottle (p < .001). This study provides a unique insight into the complexities of bottle refusal by breastfed babies and the impact it can have upon mothers' breastfeeding experiences. It generates knowledge and understanding that can help to inform practice and policies. In addition, a ‘normalising’ of the scenario could enable mothers, and those supporting them, to view and manage it more positively.     

Solid advice: Complementary feeding experiences among disadvantaged parents in two countries

The initiation of complementary feeding (CF; introducing infants to food/drink other than milk) is recommended close to 6 months and not before 4 months of age. Low socio‐economic status (SES) is a determinant of nonadherence to CF recommendations, but there is an evidence gap around reasons for nonadherence among these parents. This study investigated knowledge, attitudes, and practices of disadvantaged families (in terms of SES and social support) and use of guidance for CF, in the Republic of Ireland and Northern Ireland. Parents of infants aged 3–14 months were recruited via community groups. Semistructured focus groups aided by vignettes were used. Data were analysed using an inductive thematic approach. Nineteen focus groups took place with parents (n = 83). A range of factors influence parents when introducing solids. Sources of guidance extend to family, friends, the internet, and commercial resources. Parents experience uncertainty and anxiety during this time, driven by lack of knowledge and conflicting advice. Five major themes were identified: (a) more guidance that is accessible, timely, and respectfully needed; (b) the challenge of choosing safe, nutritious food; (c) “everybody has an opinion”; (d) feelings of inadequacy, embarrassment, and guilt; and (e) decisions are ultimately based on individual circumstances. CF advice should be culturally appropriate, practical, and empowering, emphasising the rationale behind updates to recommendations and consequences of nonadherence. Future training of health professionals for delivery of CF advice and guidance should consider these findings. Compliance with CF recommendations is influenced by health professionals, the wider family, and the commercial baby‐food sector.     

Conflicting influences on UK mothers' decisions to introduce solid foods to their infants

Adherence to recommendations to wait until 6 months to introduce solid foods into infants' diets is very poor. An in‐depth understanding of the factors involved in this decision is essential if health practitioners are to offer suitable advice and health education. A cross‐sectional electronic questionnaire study was conducted with 105 mothers recruited via UK‐based Internet parenting discussion forums. Ratings of variables important in making the decision to introduce solid foods were analyzed using factor analysis and multiple regression. Open‐ended questions were analyzed qualitatively using content analysis. In this sample of educated women, later weaning was found to be associated with a focus on the importance of the recommendations and a perception that health visitor advice and support was poor. Earlier weaning was associated with a focus on the importance of putative weaning signs from the baby. Qualitative analysis revealed a number of conflicting influences on the decision about when to give solid foods: recommendations, guidelines and advice, signs from the baby, beliefs about solids and maternal considerations. The conflict that some mothers experience in deciding when to give their babies solid food between the rigid recommendations, more tailored guidance from health professionals and their perceptions of putative weaning signs from their infants poses a particular problem for those attempting to provide clear and helpful health education information. Future research must assess the extent to which this conflict is prevalent in the general population, and investigate the salience and utility of different health education messages to promote good infant health.     

High sugar content of European commercial baby foods and proposed updates to existing recommendations

The aim was to determine whether commercial baby foods marketed within Europe (up to 36 months of age) have inappropriate formulation and high sugar content and to provide suggestions to update European regulations and recommendations as part of a nutrient profile model developed for this age group. The latter was produced following recommended World Health Organization (WHO) steps, including undertaking a rapid literature review. Packaging information from countries across the WHO European region was used to determine mean energy from total sugar by food category. The percentage of products containing added sugar and the percentage of savoury meal‐type products containing pureed fruit were also calculated. A total of 2,634 baby foods from 10 countries were summarised: 768 sold in the United Kingdom, over 200 each from Denmark (319), Spain (241), Italy (430) and Malta (243) and between 99–200 from Hungary, Norway, Portugal, Estonia and Slovenia. On average, approximately a third of energy in baby foods in these European countries came from total sugar, and for most food categories, energy from sugar was higher than 10%. Use of added sugars was widespread across product categories, with concentrated fruit juice most commonly used. Savoury meal‐type purees did not contain added sugars except in United Kingdom and Malta; however, fruit as an ingredient was found in 7% of savoury meals, most frequently seen in UK products. Clear proposals for reducing the high sugar content seen in commercial baby foods were produced. These suggestions, relating to both content and labelling, should be used to update regulations and promote product reformulation.     

Fat intake and metabolism in Swedish and Italian infants

The purpose of the study was to compare fat intake and metabolism between two infant populations from Sweden and Italy given breast milk or similar infant formulas, but different weaning foods. Nutrient intake and fat metabolism were studied prospectively from 3-12 mo in 68 Swedish and 46 Italian healthy infants, breastfed or given similar infant formulas in combination with Swedish or Mediterranean weaning foods. Although nutrient intake and fat metabolism were similar at 6 mo, fat intake was lower at 12 mo in the Italian than in the Swedish formula group (p < 0.001). At 6 and 12 mo, higher dietary ratios of monounsaturated to saturated fatty acids (p < 0.01 and p < 0.001, respectively), and monounsaturated to polyunsaturated fatty acids (p < 0.05, p < 0.001) were found in the Italian than in the Swedish formula group. Total cholesterol and apolipoprotein B were lower at 6 mo (p < 0.01) in Italian breastfed infants than in Swedish ones. Lower concentrations at 6 and 12 mo of total cholesterol (p < 0.05, p < 0.05, respectively), apolipoprotein B (p < 0.05, p < 0.01) and triglycerides (p < 0.001, p < 0.01), and of apolipoprotein A1 (p < 0.01) at 12 mo, were found in the Italian formula group than in the Swedish one. In conclusion, plasma total cholesterol, apolipoprotein B and triglycerides were found to be lower in Italian infants than in Swedish infants during the second half of infancy. These findings may partly result from differences in fat compositions between Swedish and Mediterranean weaning diets and in total fat intake in late infancy. Differences in duration of breastfeeding and possibly in breast milk composition may also have influenced our results.     

Spoonfeeding is associated with increased infant weight but only amongst formula‐fed infants

Infant feeding experiences are important for the development of healthy weight gain trajectories. Evidence surrounding milk feeding and timing of introduction to solids is extensive; however, the impact of the method of introducing solids on infant growth has been relatively underexplored. Baby‐led weaning (where infants self‐feed family foods) is proposed to improve appetite regulation, leading to healthier weight gain and a reduced risk of obesity. However, the evidence is mixed and has methodological inconsistencies. Furthermore, despite milk being a large part of the infant diet during the period infants are introduced to solid foods, its influence and interaction with introductory style have not been considered. The aim of this study was to explore growth among infants aged 3–12 months according to both style of introduction to solid foods and milk feeding; 269 infants were weighed and measured, and body mass index (BMI) computed. The results showed that overall, infants who were spoon‐fed (compared with self‐fed) at introduction to complementary feeding (CF) had greater length (but not weight or BMI). However, when milk feeding was accounted for, we found that infants who were both spoon‐fed and fully formula fed had greater weight compared with spoon‐fed, breastfed infants. There was no significant difference in weight among self‐fed infants who were breastfed or formula fed. The results highlight the importance of considering infant feeding as a multicomponent experience in relation to growth, combining both milk feeding and method of CF. This relationship may be explained by differences in maternal feeding style or diet consumed.     

Iodine status and associations with feeding practices and psychomotor milestone development in six‐month‐old South African infants

Iodine is important for normal growth and psychomotor development. While infants below 6 months of age receive iodine from breast milk or fortified infant formula, the introduction of complementary foods poses a serious risk for deteriorating iodine status. This cross‐sectional analysis assessed the iodine status of six‐month‐old South African infants and explored its associations with feeding practices and psychomotor milestone development. Iodine concentrations were measured in infant (n = 386) and maternal (n = 371) urine (urinary iodine concentration [UIC]), and in breast milk (n = 257 [breast milk iodine concentrations]). Feeding practices and psychomotor milestone development were assessed in all infants. The median (25th–75th percentile) UIC in infants was 345 (213–596) μg/L and was significantly lower in stunted (302 [195–504] μg/L) than non‐stunted (366 [225–641] μg/L) infants. Only 6.7% of infants were deficient. Maternal UIC (128 [81–216] μg/L; r_s = 0.218, p < 0.001) and breast milk iodine concentrations (170 [110–270] μg/kg; r_s = 0.447, p < 0.0001) were associated with infant UIC. Most infants (72%) were breastfed and tended to have higher UIC than non‐breastfed infants (p = 0.074). Almost all infants (95%) consumed semi‐solid or solid foods, with commercial infant cereals (60%) and jarred infant foods (20%) being the most common solid foods first introduced. Infants who reported to consume commercial infant cereals ≥4 days weekly had significantly higher UIC (372 [225–637] μg/L) than those reported to consume commercial infant cereals seldom or never (308 [200–517] μg/L; p = 0.023). No associations between infant UIC and psychomotor developmental scores were observed. Our results suggest that iodine intake in the studied six‐month‐old infants was adequate. Iodine in breast milk and commercial infant cereals potentially contributed to this adequate intake.     

Book Reviews

Books Reviewed:
Wendy K. Silverman and Philip D. A. Treffers, Anxiety Disorders in Children and Adolescents: Research, Assessment, and Intervention
J. Hill and B. Maughan, Conduct Disorders in Childhood and Adolescence