CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
NUTRITION IN THE FIRST YEAR OF LIFE
A thesis submitted in partial satisfaction
of the requirements for the degree of
Master of Science in
Home Economics
by
Laurie Keil Leeb
May, 1983
The Thesis of Laurie Keil Leeb is approved:
Ann R. Stasch, Ph.D., Chairperson
California State University, Northridge
ii
To Fred, whose patience and confidence
encouraged me to complete my graduate
studies.
iii
ACKNOWLEDGEMENTS
I wish to express sincere appreciation and thanks
to the following people:
Dr. Ann Stasch, my advisor, committee chairperson,
and friend for her practical advice and expert guidance.
Dr. Molly C. Gorelick, for her continual interest
and support in my academic and professional future.
Dr. Lillie Grossman for her contributions to this
study.
The Staffs and Parents of:
A Place for Parents
Infant Classes, California State University, Northridge
Infant Class; Long Beach City College Infant Classes; and
Reseda Adult School Infant Class; who took their time to
complete my questionnaire.
Dr. Jim Fleming for his time and effort in helping
me compute and analyze the data.
Diane, Cindy Delson and Sue Kleinfelter for their
quality typing jobs.
My daughter Jessica and her friend Rhoda Couch,
whose harmonious relationship permitted me to have the
time to complete my Masters Degree.
My mom, dad and sister whose long distance love
and support is always a part of everything I do.
iv
TABLE OF CONTENTS
Page
DEDICATION • • .
.
.
ACKNOWLEDGEMENTS .
. iii
iv
LIST OF TABLES AND FIGURE
. vii
ABSTRACT
. . viii
Chapter
1.
2.
INTRODUCTION
1
Justification .
2
Objective . •
3
Assumptions .
3
Limitations .
3
Definitions of Terms
3
REVIEW OF LITERATURE
5
Energy and Nutrient Needs .
5
Stages of Development .
6
Historical Background
9
What Foods to Feed
.
.
.
.
.
. . . . 12
18
Feeding Process
Obesity . . . . . .
• • 20
Dental Care
.
Nutrition Education .
3.
f-'lETHODOLOGY .
23
•
Procedure .
v
. 21
•
•
• 25
•
• 25
Page
Data Collection .
.
. 25
Analysis of Data
4.
• • 26
RESULTS AND DISCUSSION
• • 27
Feeding Practices .
Nutrition Assessment
5.
SUMMARY, CONCLUSIONS, AND
RECOMMENDATIONS . . . . .
Summary and Conclusions .
• 27
.
.
.
. 36
• • • 42
• • 42
Recommendations for Further Study .
. 45
•
• 47
.
• 51
Appendix A - Recommended Dietary Allowances .
. 52
LIST OF REFERENCES .
APPENDICES .
• .
.
•
.
Appendix B - Questionnaire
vi
53
LIST OF TABLES AND FIGURE
Page
Table
1.
Factors Considered When Introducing Solid
Foods .
2.
3.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
• 31
Responses to Questions Regarding Use of
Solid Foods . . . . .
• . . • . .
.
. 33
List of Foods Infants Ate and Enjoyed
Ranked by Number of Responses . . . • .
.
.
. 35
Question 8 - Factors Ranked First in
Influencing Infant Feeding Practices
.
.
. 28
Figure
1.
vii
.
ABSTRACT
NUTRITION IN THE FIRST YEAR OF LIFE
by
Laurie Keil Leeb
Master of Science in Home Economics
The practices and knowledge of mothers in the
area of infant feeding may have a profound effect on the
young child's future eating behavior.
The objective of this study was to determine the
current knowledge of mothers with regard to general nutrition and the method of introduction of solid foods to
their infants.
A review of the literature showed that
mothers primarily rely on their pediatrician for nutrition information and generally comply with what he/she
advises.
The recommended age for solid food introduction
is four to six months.
A questionnaire was distributed to first-time
mothers attending mother-infant classes.
The results
showed that the mothers were generally college educated
without any formal nutrition training.
viii
Consequently,
they depended on their pediatrician for the nutrition
information they needed.
The majority of mothers had an
overall understanding of general nutrition principles,
yet lacked the knowledge of some specific diet/nutrient
needs of infants.
Solid foods were introduced between four and six
months, and all the children on solid foods at the time
of the study were consuming a wide variety of high nutrient density foods.
ix
CHAPTER 1
INTRODUCTION
The period of life when an individual undergoes
the most rapid rate of growth and development is in infancy (Andrew, et al., 1980; Pipes, 1981).
Changes in
relation to food and nutrient intakes occur more rapidly
in the first twelve months than in any other stage of the
life cycle.
Through food, many of a baby's physical, emo-
tional and social needs are met.
Infant feeding serves
more than a nutritional purpose as it plays an important
role in the infant's first impressions of the world.
Little evidence is available to document the longterm consequences and future manifestations of infant
feeding practices.
But there is some evidence that what
an infant eats and the experience of eating may have an
influence on his/her mental and physical health in adulthood.
This study explores and assesses what solid food
infants are eating and when, why and how they are introduced.
The initial food of a healthy full-term newborn
baby is typically milk from its mother's breast or a proprietary formula closely resembling human milk.
The
switch from milk to solids in the first year of life is
an exciting and rewarding, but challenging, transition.
1
2
The basis of knowledge in beikost feeding reflects both
researched and/or undocumented information.
Present pat-
terms of introducing solid foods have not been well described (Andrew, et al., 1980) and the American Academy of
Pediatrics (AAP, 1980) found recommendations for introducing these into the diet to differ.
Justification
It is still not established whether inappropriate
nutrition in infancy will have a cause-and-effect relationship with metabolically-related disorders in adulthood.
Questions regarding the associations between early
feeding practices and later conditions of obesity, hypertension, atherosclerosis and lifetime eating habits are
still unanswered.
If the eating behavior in the first year of life
lays the foundation for future health then such behaviors
and patterns of eating need to be documented.
There is
little information available on the sources of energy or
composition of infants' diets (Andrew, et al., 1981).
If
such information were available, nutritionists and other
health professionals would have better insight into current trends of feeding beikost, and what if any modifications caregivers need to make in their current practices.
3
Objective
The objective of this study was to determine the
current knowledge of mothers with regard to introducing
beikost to their infants.
Assumptions
It was assumed that the questionnaire is a valid
instrument to determine mothers' current practices with
regard to infant feeding, specifically solid foods.
Limitations
The researcher recognized the following
limitations of the study:
1.
The questionnaire was completed only by those
parties that agreed to participate.
2.
Distribution of the questionnaire was limited
to groups of mothers participating in "mommyme" classes.
Definition of Terms
Beikost:
German word meaning foods other than
milk or formula.
Caregiver:
Mother, father or another adult
responsible for an infant.
4
Dental Caries:
Localized progressive decay of
the teeth, initiated by demineralization of the outer surface of the tooth due to organic acids produced locally by
bacteria that ferment deposits of dietary carbohydrates
(Fomon, 1974).
Infancy:
The first twelve months after birth.
Kilocalories (kcal):
The measure of the amount
of heat energy necessary to raise the temperature of 1,000
grams of water 1° Centigrade.
Used interchangeably with
calorie.
Solid Foods:
Used interchangeably with beikost.
Foods other than milk or formula.
CHAPTER 2
REVIEW OF LITERATURE
Energy and Nutrient Needs
During the first year, a baby grows rapidly, with
birth weight doubling by six months and tripling at a
year (Whitney and Hamilton, 1981; Woodruff, 1978).
That
equates to one ounce of weight gain daily in the first six
months and about one and one-half ounces daily in the second six months (Driggers, 1980).
An infant's metabolism
is relatively fast and energy needs are high (an infant's
heart beats 120-140 beats per minute compared to 70-86
beats per minute for an adult).
The respiration rate is
20 times a minute in a baby in contrast to 12-14 times a
minute in an adult (Hamilton and Whitney, 1982).
To meet
these high energy demands a careful balance between energy
requirements and energy intake is necessary in the first
twelve months.
This is needed to maintain the child's
body for normal growth and development.
The average kilocalorie requirement in the first
year is between 100-120 per kilogram of body weight a day
(Barness, 1979; Driggers, 1980; Filer, 1978; Woodruff,
1981).
This relationship usually remains constant
throughout the first year to meet growth needs and satisfy
5
6
the increase in activity needs (Hamilton and Whitney,
1982).
Energy is provided by:
fats, carbohydrates and
proteins in approximate amounts of nine, four and four
kilocalories per gram, respectively (Fomon, 1974).
Seven
to sixteen percent of daily kcal intake should be provided
by protein, 35%-55% by fats and the remaining amount by
carbohydrates (Heslin, et al., 1980).
Minimum vitamin and mineral requirements also have
been established to meet the young infant's nutrient
needs.
The latest figures have been published by the
National Academy of Sciences in their Recommended Dietary
Allowances (RDA)
(see Appendix A)
(Hamilton and Whitney,
1982).
Stages of Development
Children develop in an orderly pattern physically,
emotionally and psychologically (Pipes, 1981; AAP, 1980).
Normal infants are born with the reflex abilities to root
for a nipple and to suck and swallow only liquids (Green
and Johnston, 1980).
As the infant grows, oral, fine, and
gross motor skills mature to allow him/her to ingest and
accept new foods.
This will gradually allow the infant to
chew, self-feed, and hold his/her own bottle and utensils
(Endres and Rockwell, 1980).
The AAP defines three stages of feeding infants
(AAP, 1980).
These periods delineate physical,
7
psychological and physiological changes in the infant.
The nervous system, intestinal tract, and kidneys are also
factors in determining maturation.
Chronological age
alone is too arbitrary a measurement to assess readiness
for diet changes (Pipes, 1981).
An infant is born into the "nursing stage.''
The
AAP (1980) describes this stage as one that lasts between
four and six months.
During this time the best source of
fats, carbohydrates and proteins is from milk as the gastrointestinal (GI) tract is not well equipped to digest
proteins, fats and carbohydrates from other food sources.
The kidneys are also unable to handle large osmolar loads
of protein and electrolytes (Markesbery and Wong, 1979).
Breast milk, or a cow, goat or soy milk based,
commercially prepared formula, usually provides the newborn with the energy, vitamins and minerals it needs without undo stress on the kidneys, intestine or GI tract
(Hamilton and Whitney, 1982; AAP, 1980).
The strong de-
pendency an infant has on milk makes it critical that it
contain the essential components tailored to meet the
baby's nutrient requirements.
Though breast milk is cur-
rently the milk of choice for an infant (AAP, 1980;
Barness, 1979; Endres and Rockwell, 1980; Driggers, 1980;
Nutrition Review, 1980), fortified commercial formulas
meeting the standards set by the American Academy of
l
8
Pediatrics are an adequate alternative (Andrew, et al.,
1981; Woodruff, 1978).
As the extrusion reflex disappears the infant
begins to swallow nonliquids and moves into stage two, the
"transitional stage.''
This occurs around five to six
months of age (AAP, 1980).
By that time the infant has
developed the neuromuscular mechanisms needed for masticating and swallowing nonliquids, can usually sit with
support and has good control of the head and neck.
The
intestinal tract can digest non-milk proteins, fats and
carbohydrates.
The kidneys can handle greater osmolar
loads with less water.
The "transitional stage" is the optimal time to
introduce beikost into the diet of an infant (AAP, 1980;
Endres and Rockwell, 1980; Crummette and Munton, 1980;
Fomon, 1974; Kirk, 1980; Pipes, 1981).
The infant can
express desire for food by opening his/her mouth and leaning forward, and disinterest or satiety is indicated by
leaning back and turning away (Driggers, 1980).
Milk in-
take may also reach seven ounces at one feeding, indicating that smaller, more frequent meals are needed since
energy needs are increasing (Fomon, et al., 1979; Leach,
1980).
In this stage the infant appreciates tastes and
colors, is physiologically capable of accepting foods from
a spoon and transferring them from the front of the mouth
to the back for swallowing (Bordeaux, et al., 1982; Endres
'
9
and Rockwell, 1980).
Turner and Turner (1981) stated
that there may also be some evidence of an interest in
self-feeding.
According to the American Academy of Pediatrics
(1980), the last feeding stage an infant graduates to in
the first year is the "modified adult period."
iod usually occurs at one year of age.
This per-
In this stage,
physiologic mechanisms have matured to near adult proficiency, self-feeding (with family foods that have undergone minimal alteration) , is achieved and taste ability and
preferences are becoming clearly established.
Foods to
introduce in the "transitional stage" and "modified adult
period" are addressed in the following section "Introducing Beikost."
Historical Background
Information regarding the transition from milk to
solids has been a victim of folklore and fads.
Caregivers
have based their practices of feeding solids to infants
primarily on invalid information (Butler, et al., 1954;
Driggers, 1980).
Until about the 1930's solid foods were
seldom offered before one year of age.
By that time pedi-
atricians began to recognize solid food feedings to be safe
at 6 months.
In the 1950's a new perspective on the issue
evolved and the feeding of solids began in the first weeks
of life (Pediatrics, 1958).
The reasons for this were
10
many.
Mothers wanted to see a rapid weight gain,
convenience foods were more available, and caregivers
thought it would encourage sleeping through the night
(AAP, · 19 8 0) •
The belief that there was an advantage in feeding
solid foods early to help babies sleep through the night
was challenged by several researchers.
Grunwaldt, et al.
In the 1960's,
(1960) found no statistical correlation
between solid foods in the diet and the age at which the
infant began to sleep through the night.
Guthrie (1966)
also found there was no association between feeding solids
early and the onset of uninterrupted night sleeping.
How-
ever, early feeding of solids for this reason was still
supported by some physicians (Sullivan, 1981; Guthrie,
1966; Fomon, 1975; Pediatrics, 1979).
Attempts to increase caloric intake, such as
feeding infants at bedtime, should be avoided (Fomon,
et al., 1979).
Pipes (1970) stated that this practice,
along with the general trend of introducing solid foods
early, may reinforce excessive energy intakes.
This may
encourage over feeding and the establishment of unsound
food habits (Fomon, 1974).
There is inadequate documen-
tation as to whether the early introduction of solid foods
can be associated with adult obesity (Bordeaux, et al.,
1982; Himes, 1979; Tsang and Nichols, 1981; Woodruff,
1981) .
Studies have concluded that there is no
11
relationship between age of introducing foods and the
development or persistence of obesity.
Only in the case
where solid foods are not displacing the calories from
milk, but adding to them, does overweight occur (AAP,
1980).
In 1966, GuthFie studied the effect of early
feeding of solids on the nutrient intakes of infants.
She found that the nutritive content of the diets of
babies in the study did not increase with the early introduction of solid foods.
Other research has documented
that the volume of milk intake is lowered when solids are
introduced early (Pediatrics, 1958; Pipes, 1977).
The
optimal balance of fats, carbohydrates, and proteins in
milk will be altered if food is introduced too early
(Markesbery and Wong, 1979).
Total calories may be ade-
quately met with solid foods; however, the nutritional
state of the infant may be worsened at the expense of milk
(Pediatrics, 1980; Pipes, 1977).
The absorption of iron
from breast milk decreases when foods are introduced
(Endes and Rockwell, 1980).
Delaying beikost introduction
or adding iron to the breast fed infant's diet when foods
are started is especially important (Dallman, 1980).
Today, most professionals don't see an urgent
need to introduce solid foods early.
They advise care-
givers to wait until four to six months of age (Filer,
1978; AAP, 1980).
At this age, the infant is
12
physiologically mature, should begin to sit on his/her
own, demonstrate rotary chewing movements, be able to
grasp easily manipulated foods and have voluntary hand
to mouth movements (Pipes, 1981).
What Foods to Feed
Moving from a diet consisting only of milk to one
which includes solids is an important landmark in an infant's life (Turner and Turner, 1981).
Foods which are
fed to a child at this step in infant feeding are subject
to cultural, ethnic, social and economic factors (Pipes,
1981).
In the beginning, breast milk or formula will
still supply the major portion of calories and nutrients.
The beikost will give the infant an opportunity to learn
about and enjoy foods of differing tastes, colors, and
textures (Woodruff, 1981).
At meal times, the interest
to experiment with new foods may be heightened, by first
giving milk to take the edge off of the baby's hunger
(McDonald, 1975).
The future development of lifelong
dietary habits may be dependent around the nature (variety) and timing of these solid food feeding practices
(Woodruff, 1978; Crumrnette and Munton, 1980).
Although many researchers report that the order
of introducing beikost is not critical, iron-fortified
rice cereal has traditionally been the first food prepared
for infants (AAP, 1980; Barness, 1979; Bordeaux, et al.,
13
1982; Endres and Rockwell, 1980; Pipes, 1981).
Iron
deficiency is the number one cause of anemia in infants.
The most critical time
for this is around six months in
a full term infant, which is approximately the time when
infant iron stores are depleted (Committee on Nutrition,
1976; Woodruff, 1978).
Especially in breastfed infants,
iron needs must be met with food or a supplement at this
time (Tsang and Nichols, 1981).
To avoid potential prob-
lems of anemia, iron-fortified cereals are recommended as
a good source of iron for all children in the first 18-24
months (Fomon, et al., 1979; Yeung, et al., 1981).
Caregivers should be aware of manufacturers'
reconstitution guidelines for infant cereals.
Depending
on the cereal it may be best to mix it with milk or water.
The difference may affect the quantity and quality of
nutrients the infant receives from the food (ESPGAN Committee on Nutrition, 1981).
Once baby cereals are mixed
properly they are excellent foods and are difficult to
duplicate from scratch in a residential kitchen (Leach,
1980).
Once fortified baby cereal is accepted, other
foods can be introduced one at a time (Bordeaux, et al.,
1982).
There is no evidence that introducing fruits be-
fore vegetables affects vegetable acceptance (Fomon,
et al., 1979); however, some professionals say fruits
develop a preference for sweets.
This could lessen a
14
baby's liking of vegetables (Whitney and Hamilton, 1981).
In any case, starting slowly with a teaspoon or less of a
new food and working up to 2-3 tablespoons/meal in a week
or two is suggested (McDonald, 1975).
By adding new
foods singly at intervals of no more than one every three
days or one to two foods a week (Fomon, et al., 1979;
Pipes, 1981), allergies can be detected (AAP, 1980).
Mixed foods should be avoided initially because if a food
is too complex, allergic reactions cannot be easily traced
back to the source (McDonald, 1975; Caplan, 1973).
Com-
bined foods can be added to the diet after tolerance of
individual components has been established (AAP, 1980).
To date there are few reliable methods to verify
and diagnose infant food allergies.
Two ways to minimize
the risk of food allergies in infants would be to continue
breast feeding until six months of age or to withhold
foods most commonly linked to allergies (AAP, 1980; Tsang
and Nichols, 1981).
The introduction of wheat, egg
whites, citrus fruits and cow's milk may be postponed
until late in the first year however these foods are sometimes unjustifiably denied because of false allergenic
symptoms (AAP, 1980; Bordeaux, et al., 1982; Pipes, 1977).
Strained, pureed foods can be made at home or
purchased commercially in a great variety.
Foods prepared
at home usually have a greater energy content (Pipes,
1981) than their commercial counterparts which contain
15
more water and less fat (Woodruff, 1978; Fomon, 1974;
ESPGAN Committee on Nutrition, 1981).
When preparing
foods at home hygiene should be closely watched to avoid
spoilage (AAP, 1980).
Carefully selected, unsalted, un-
sweetened, fresh foods should be used (Pipes, 1981).
Contrary to the old belief that sodium chloride (table
salt) makes food more palatable to the infant, Fomon,
et al.
(1970) found no difference in consumption of foods
when table salt was or was not added.
Commercially processed foods are generally of
adequate nutrient quality, are convenient and generally
safe, if used within a 24-48 hour period after opening
(ESPGAN Committee on Nutrition, 1981).
They are expensive,
however, and unnecessary additives may be in the dinners
and desserts (e.g., corn syrup, tapioca, corn starch) to
increase shelf life (Pipes, 1981; Whitney and Hamilton,
1981).
The use of commercially prepared baby foods has
extended into the last months of the first year (Andrew,
et al., 1981).
Two-thirds of the infants in a study by
Maslansky, et al.
(1974) were still eating commercial
infant foods at eleven months.
Other infants between six
and eighteen months were found to eat only prepared baby
foods except for eggs.
Commercial foods tend to be bland,
not giving the baby a chance to become accustomed to a
variety in taste and texture.
These food items also do
16
not look like what adults eat and are impossible for
finger feeding.
A reasonable compromise when planning
the infant's diet is to use both homemade and commercial
baby foods
(Leach, 1980}.
The best encouragement for self-feeding is to
minimize the spoon feeding of pureed and strained foods.
An infant does not need teeth to eat coarser foods, soft
foods can adequately be chewed with the gums (Lansky,
1976}.
Mixing coarser pieces of food with strained foods
or giving the infant chunks of it separately will gradually get him/her accustomed to the new textures.
Posi-
tive encouragement of independent eating, no matter how
messy, teaches the infant to self-feed (Crummette and
Munton, 1980; Endres and Rockwell, 1980; Leach, 1980}.
If
finger foods are withheld when the child is ready to chew
them, there may be difficulty in later acceptance (Lansky,
1976; Pipes, 1981; Williams, 1977}.
The caregiver re-
ceives cues when the infant is ready for finger foods
(Williams, 1977}.
The infant will exhibit the ability to
put objects in his/her mouth and chew on them, usually
around six to seven months.
By eight or nine months a
baby should have the ability to eat almost all family
foods that are chopped, cooked and lightly seasoned
(Williams, 1977}.
Excessively salty and fatty foods, hot
spices, alcohol, coffee, tea and refined sweets should be
17
avoided (Kirk, 1980; Leach, 1980; Maslansky, et al., 1974;
Williams, 1977).
Fluids are needed during the time when solid
foods are introduced.
When solid food becomes integrated
into the diet there is greater protein and electrolytes
and an increase in the renal osmolar load.
The American
Academy of Pediatrics (1980) suggests offering water at
mealtimes to fulfill fluid needs without additional calories.
Partitioning and complementing milk intake with
solids is a difficult procedure.
In addition to solid food, the AAP recommends
that infants not being breast fed receive formula throughout the first year (Pipes, 1981; Woodruff, 1981).
The
introduction of cow's milk should occur when the GI tract
reaches immunologic maturity at about one year.
In con-
trast, several researchers report that whole cow's milk is
safe in the diet of infants when they are consuming at
least 200 grams (1-1/2 jars or 3/4's cup of food) of solid
foods daily.
This can be done as early as six or seven
months, generally when the infant will no longer show a
negative reaction to cow's milk (Andrew, et al., 1981;
Endres and Rockwell, 1980; Fomon, et al., 1979; Leach,
1980).
An adequate diet for a six month old baby can con-
sist of about 30-32 ounces a day of milk and approximately
200 kilocalories from beikost (Driggers, 1980; Fomon,
et al., 1979; Leach, 1980).
The diet of an infant
18
consuming either formula or cow's milk needs to include
more fruits, vegetables and juices than meats and other
protein rich foods.
When cow's milk is given, other foods
rich in iron and vitamins A, C and D should also be included (Andrew, et al., 1981; Fomon, et al., 1979).
A
breast fed baby needs to get foods rich and moderately
high in protein (AAP, 1980; Andrew, et al., 1981; Fomon,
etal., 1979).
The high protein composition of cow's milk
increases the solute load that must be excreted by the
kidneys (Pipes, 1981; Woodruff, 1981).
This has been di-
rectly associated with enteric blood loss when intake exceeds one quart of milk a day (Pipes, 1981).
Cow's milk
has also been associated with iron deficiency (Hamilton
and Whitney, 1982; Woodruff, 1981).
Non-fat cow's milk
feedings have been linked to the undesirable mobilization
of body fat to meet energy needs (Fomon, et al., 1977;
Driggers, 1980).
Low fat diets which include non-fat
cow's milk have a low satiety value and do not adequately
satisfy the thirst or appetite of an infant (Andrew,
et al., 1981; Barness, 1979).
Feeding Process
Lifelong eating patterns begin at the onset of
solid food introduction (Woodruff, 1978).
The feeding
attitude on the part of the caregiver, the climate the
19
food is being fed in, the availability of food, the
choice of foods, and the tools used in feeding all directly influence the emotional and nutritional well-being
of the infant (Butler, et al., 1954; Maslansky, et al.,
19 7 4 ; Pipes , 19 81) .
It is important to cultivate a relaxed and
accepting attitude so the baby enjoys food.
Eating should
not become a duty (Endres and Rockwell, 1980; Leach, 1980)
The Review of Literature supports three basic rules of
happy eating:
1) don't impose ideas of suitable combinations
2) don't impose eating courses in a "proper" order
and
3) don't force foods not eagerly wanted.
(Leach, 1980; McDonald, 1975).
The use of brightly
colored plastic dishes and placemats, and a sunny spot
in the kitchen elicits an enjoyable eating experience
(McDonald, 1975).
The caregiver has an obligation to remember that
the infant's needs are best served on an individual
basis, and rigid schedules may not fit their variable
development (Crummette and Munton, 1980; Pediatrics, 1958;
Woodruff, 1978).
A child may show signs of always being
hungry yet be receiving enough food for its needs in a 24
hour period.
The problem may be that the pre-determined
mealtimes when pre-set quantities are served are not
20
necessarily meeting immediate hunger or appetite needs,
only nutrient needs (Leach, 1980).
The caregiver is re-
sponsible for recognizing hunger and satiation, and adjusting the diet by increasing or decreasing quantities
appropriately (Pipes, 1981).
The baby should not have to
fit a diet, the diet should fit the baby (McDonald, 1975).
Pipes (1981) reminds caregivers that food is not
always the answer to satisfy an infant's discomfort.
Us-
ing food in this manner may teach the. child to rely on
eating as a means to satisfy a wide variety of needs.
Obesity
Excessive weight gain in infancy depends on a
simple equation:
energy intake = energy output (Health
Learning Systems, 1979; Woodruff, 1978).
Babies should
not learn to seek food as a reward, as a pacifier, as a
comfort measure for unhappiness, or to associate its deprivation with punishment (Whitney and Hamilton, 1981;
Woodruff, 1981).
An infant should be permitted to stop
eating at the earliest signs of satisfaction, not at the
maximum consumption point (Fomon, et al., 1979).
Weight gain is a gross body measurement and
therefore is not conclusive in defining obesity (Himes,
1979).
However, if an infant's weight gain is in the
95th percentile and increasing more rapidly than length
growth, then treatment involves slowing down the rate of
21
weight gain in proportion to linear growth.
This should
not result in actual weight loss (Barness, 1979; Endres
and Rockwell, 1980).
There are potential risks of impos-
ing reducing diets in early infancy (Filer, 1978).
Diet
restriction may decrease the amount of fat-free body
tissue, inhibit normal growth and decrease energy reserves
needed in stressful periods (Endres and Rockwell, 1980).
Practical dietary changes for infants gaining
excessive weight can be accomplished by 1) shifting the
use of high calorie dense foods to lower calorie dense
foods; and 2) quenching thirst with water, not milk
(Bordeaux, et al., 1982; Himes, 1979; Whitney and Hamilton,
1981).
Fomon (1977) does not recommend that infants be
put on skimmed cow's milk for weiqht control.
He warns
against the potential problem of unwanted weight gain if
high calorie foods are later consumed in quantities to
achieve similar gastric filling when only skim milk was
consumed.
Dental Care
Sound nutrition during the early period of life
affects the dental health of a child.
As early as 1862
an observed association was noted between dental caries'
and the offering of milk or sweetened beverages in the
bottle at bedtime.
Under circumstances of bedtime feed-
ing, sucking and swallowing are infrequent, and salivary
22
flow is minimal (Fomon, 1974).
The decrease in salivary
flow rate during sleep makes the dentition more susceptible to acid production and bacteria (Driggers, 1980;
Pediatrics, 1977).
This problem is known as "milk-bottle
caries," or "nursing bottle syndrome" (Barness, 1979;
Driggers, 1980).
Infants should be held while taking a bottle.
If
the infant falls asleep with the bottle, the high carbohydrate mixture of the fluid remains in his/her mouth near
budding teeth.
The milky film bathes the upper teeth with
a continual flow of carbohydrate rich fluid, breeding decay on the back of them (Fomon, 1974; Lansky, 1976;
Whitney and Hamilton, 1981).
The introduction of juice
should be delayed until it can be consumed from a cup to
decrease caries production (Endres and Rockwell, 1980,
Pipes, 1981).
The magnitude of the problem was made evi-
dent by the research of Andrews, et al.
(1980).
They ob-
served that twenty-five percent of a group of children
between two and twelve months old received "other" sweet
beverages (e.g., juice, fruit drinks) in a bottle instead
of milk.
Healthy dental development before and after
eruption of primary teeth can be promoted by nutritious
foods, avoiding low nutrient density sweets and filling
the bottle that goes in bed (if it must) only with water
(Pediatrics, 1977).
23
Nutrition Education
The art of infant feeding encompasses the
practical application of nutrition information (Woodruff,
1978).
Nutrition practices and diet management of an in-
fant are influenced by the caregiver's past experiences,
social milieu, media exposure, socioeconomic status,
ethnic background, and contact with health professionals
(Andrews, et al., 1980; Crummette and Hunton, 1980;
Driggers, 1980).
However, most parents turn to their
pediatricians for recommendations on how to feed their
infant.
In the research available that addresses eating
practices in early infancy, there is little indication
that pediatricians and parents are effectively cooperating (Morse, et al., 1979).
The doctors of pediatric med-
icine should concentrate their efforts to communicate effectively to parents adequate up-to-date infant nutrition
information that has clear benefits to the child (Kirk,
1980).
In the area of solid food feedings there appears
to be a controversy regarding compliance between doctors
and parents.
Mothers with greater nutrition knowledge
delayed the introduction of solid food feedings, contrary
to their doctor's recommendations to start early (Morse,
et al., 1979).
In contrast to this, Bordeaux, et al.
(1982) found a 70% compliance rate among parents in
following doctors' requests.
24
Morse, Sims and Guthrie (1979) concluded in their
study that clearer methods of objective and subjective
evaluations were needed to identify the existence and
degree of dietary compliance between the medical profession and parents.
Caregivers need to know what consti-
tutes sound eating and feeding habits, what are the
calorie and nutrient density of common foods, and what
makes up basic nutrition.
CHAPTER 3
METHODOLOGY
Procedure
A questionnaire was developed and pretested with
a sample group of first-time mothers whose child was under
a year old.
With feedback from this pilot study, the
questionnaire was revised and prepared for final distribution.
The survey was designed to assess the current
practices, needs and knowledge of first-time mothers of
a full-term healthy child under 12 months of age.
questionnaire was divided into three areas:
The
general demo-
graphic information, feeding practices, and nutrition
assessment.
A copy of the testing instrument is given
in Appendix B.
Data Collection
The questionnaire was distributed to mothers
attending established mother-infant classes in the greater
Los Angeles area.
The socioeconomic status of all the
subjects was middle to upper middle class.
The selection
of classes was done on the basis of directors and teachers
willing to participate.
Six groups consented to cooperate
25
26
in the research and dates for visits by the researcher
were set.
All questionnaires were distributed, completed
and collected at the site.
Analysis of Data
The data obtained for the questionnaires were
compiled and analyzed at the California State University,
Northridge Computer Center, using the Statistical Package
for the Social Sciences (SPSS).
Results have been de-
scribed in terms of frequency and percentage.
CHAPTER 4
RESULTS AND DISCUSSION
Seventy-seven questionnaires were completed by
mothers participating in mother-infant groups.
Seventeen
surveys were eliminated from the study due to either incomplete pages, the mother had other children, her child
had a diagnosed medical problem, was diagnosed as premature at birth, or was over the age of one year.
All
sixty infants involved in the study were born between
January 29, 1982 and December 29, 1982.
Thirty-two (53%)
of the infants were males and twenty-eight (47%) females.
Feeding Practices
The literature indicates that parents depend on
the pediatrician for recommendations on feeding their infant (Morse, et al., 1979).
According to this study 88%
of the mothers took their infants to the pediatrician at
either one, two or three month intervals.
During these
visits nutrition information was exchanged, as 43
(72%)
of the mothers ranked the pediatrician as the first or
second most influential factor on feeding practice behaviors.
Figure 1 illustrates all factors mothers ranked
first as a source of nutrition information:
23% relied
on printed media, 13% sought input from friends and
27
28
23%
Printed
Media
42%
Pediatrician
* Other Health Professionals
Figure 1
Question 8.
Factors Ranked First in
Influencing Infant Feeding
Practices
29
relatives, 10% from previous school experience, 3% from
past experience, 2% from other health professionals and
7% from other unnamed sources.
When mothers were asked to describe their method
of meal planning 29 (48%) checked that they followed a
regular pattern of feeding breakfast, lunch, dinner and
snacks.
Another 48% indicated that their child ate when
he/she was hungry, which differed daily depending oh the
day's routine.
One subject adhered to a rigid schedule
for all mealtimes and one did not complete this question.
The literature reminds caregivers that their obligation is
to meet the nutritional needs as well as hunger and appetite needs of the infant.
The meal plan should fit the
baby, the baby shouldn't have to fit the diet (Leach,
1980; McDonald, 1975).
Forty-six (77%) of the infants involved in the
study were on beikost.
Thirty-nine (85%) began it between
four and six months, three (7%) before three months and
four mothers did not indicate their child's age of introducing solid foods.
The American Academy of Pediatrics
advises parents to wait until four to six months before
feeding solids (1980).
Pipes (1977) and Bordeaux (1982)
believe that solid foods should be given by the age of
six months.
When asked when their pediatrician recom-
mended solid foods 65% said between four and six months,
30
15% didn't know, and the answers of 30% ranged from two
weeks to ten months.
Table 1 describes all the factors involved when
considering the time to introduce beikost.
asked to check as many items as applicable.
Subjects were
Whether their
child was consuming beikost or not, all (100%) of the respondents answered this question.
Parents who were not
yet including solids in their infants diet could confidently say when they would start, based on the factors
given.
The most frequently checked factor was "age."
Thirty-six (60%) of the mothers prioritized age as an
indicator for beginning solid foods.
Sleeping habits and
fussiness between milk feedings were each deciding factors
for (32%) of the mothers.
One major indicator of an in-
fant's readiness to accept solid foods is developmental
maturity.
According to the American Academy of Pediatrics
(1980) and Pipes (1981)
1
the infant should be ready to
accept foods when he/she responds to a spoon, can sit
without support and can express hunger and satiety.
Only
sixteen (27%) of the mothers in this study expressed that
development readiness was or will be considered for introducing solid foods.
Fourteen (23%) noted that family and
friends' opinions had a role in this decision.
Another
seven (11%) wrote in under "other" that their pediatrician
was consulted on this issue of when to introduce solid
foods.
31
Table 1
Factors Considered When Introducing
Solid Foods
Responses
N*
%**
Age
36
60
Sleeping Habits
19
32
Developmentally Ready
16
27
Advice from friends and relatives
14
23
Fussiness between milk feedings
19
32
7
11
Factor
Other, Doctor
* N = Number of Responses
** Percentage of people indicating the factor was
considered.
32
All (100%) of the children eating beikost at the
time of the study were consuming cereals, 95% of them had
fruits in their diets, 85% were eating vegetables and 67%,
meat.
This order of cereals, fruits, vegetables and meats
was also the sequence of food introduction among 87% of
the respondents.
Cereals were listed as the introductory
food in 83% of the infants' diets.
In the current litera-
ture by Endres and Rockwell (1980) cereal is commonly an
infant's first food.
Although a pattern did exist,
Woodruff (1978) preferred that the order of food introduction be adapted for local customs.
Penelope Leach (1980)
expressed that the early tastes of food were for the educational value as well as for its nutritional benefit.
In Table 2, the usage of finger foods and table
foods was tabulated as well as the age of introduction of
these two variations in solid foods.
Thirty-six (60%) of
the infants were eating finger foods such as crackers,
toast, vegetables or fruits.
Seven (20%) began eating
these foods between four and six months, 21 (58%) between
seven and eight months, and eight (22%) between nine and
twelve months.
table foods
When asked if their infants were eating
(or family foods), 29 (48%) said "yes."
Two
(7%) began sharing family foods between four and six
months, nine (31%) between seven and eight months, 16
(55%) between nine and twelve months, two (7%) failed to
answer.
33
Table 2
Responses to Questions Regarding
use of Solid Foods
Questions
Responses
N*
%
Is your infant eating finger foods?
Yes
No
36
24
60
40
0
0
20
58
22
At approximately what age did you begin
introducing these into his/her diet?
Before 3 months
Between 4 and 6 months
Between 7 and 8 months
Between 9 and 12 months
7
21
8
Is your infant eating table foods?
Yes
No
29
48
31
52
0
2
0
7
9
31
16
2
55
7
At approximately what age did you begin
giving him/her family foods from the table?
Before 3 months
Between 4 and 6 months
Between 7 and 8 months
Between 9 and 12 months
Blank
* N = Number of Responses
34
Bananas, carrots, peas, cheese, cereal, applesauce,
yogurt and chicken were most frequently mentioned as the
infants' favorite foods.
Looking at Table 3, a wide var-
iety of high density foods were used in the diets of these
infants, under one year of age.
This variety in flavor
and textures is said to increase the acceptance of a variety of foods later in life (Pipes, 1981).
The use of infant feeders is discouraged by
nutrition specialists.
Results of this study indicated
that 46 (77%) of the subjects also did not support this
practice of feeding cereals in a bottle.
However, five
(8%) of the mothers did employ this method of infant feeding.
Nine (15%) of the subjects did not answer this
question.
To conclude the section on Feeding Practices the
question "have you generally complied with what your
pediatrician has recommended for feeding your infant?"
was asked.
Five (8%) respondents stated that their doc-
tor hadn't given them enough information to follow, 48
(80%) said "yes," and 7 (12%) said "no."
support the finding of Bordeaux, et al.
These results
(1982), that there
was a 70% compliance rate among parents following doctor's
instructions.
35
Table 3
List of Foods Infants ate and Enjoyed
Ranked by Number of Responses
Dairy Products
Breads and Cereals
Cereal
Cheerios
Rice
Puffed Wheat
Toast
Crackers
Pasta
Pancakes
Rice
Bread Crusts
French Toast
11
7
6
1
7
6
6
2
2
1
1
Proteins (Meat, Fish,
Poultry, Eggs)
Chicken
Meat (red)
Eggs
Peanut Butter
Fish Sticks
Sardines
Tuna
8
5
3
3
1
1
1
Other
Everything
Baby foods
Cookies
Soup with noodles
Cream Cheese
French Fries
Ice Cream
Pizza
Chicken Bones
*
5
3
3
2
1
1
1
1
1
Total Number of Responses
Cheese
Yogurt
8
7
Fruits
Bananas
Applesauce
Fruits in general
Apples
Peaches
Pears
Raisins
Apricots
Oranges
Papaya
Plums
Strained pumpkin
25
9
8
5
4
4
2
1
1
1
1
1
Vegetables
Carrots
Peas
Mashed Potatoes
Vegetables in general
Squash
Sweet Potatoes
Baked Potato
Avocado
Creamed Corn
Green Beans
8
8
5
5
4
4
2
1
1
1
..
36
Nutrition Assessment
The first question in this section addressed
energy nutrients.
The six categories of essential nutri-
ents were listed and respondents were asked to circle the
three which provide calories to the body.
Fifty one (85%),
52 (87%), 52 (87%) indicated fat, protein and carbohydrates, respectively.
No one indicated water, one indi-
vidual circled vitamins and minerals and 7 (12%) subjects
left this entire question blank.
When mothers were asked to choose which
commercially prepared infant food was a significant source
of iron, cereals were correctly checked by 31 (51%).
Iron-fortified cereals are recommended as a good source
of iron for all children in the first and second years
(Yeung, et al., 1981).
indicated by 24
Commercially prepared meats were
(40%) to be major contributors to an in-
fant's iron intake and 4 (7%) indicated fruits.
Once opened, commercially prepared foods can be
stored in the refrigerator for only 24-48 hours (ESPGAN
Committee on Nutrition, 1981).
mothers were aware of this fact.
Thirty-seven (61%) of the
Five (8%) indicated they
were safe up to a week, 17 (28%) did not know and one (2%)
didn't use them.
The awareness of current terms in nutrition was
tested in Question 28.
Forty-three (72%) of the mothers
knew that a low nutrient density food was one which
37
contained more calories in relation to other nutrients.
Only seven (12%) completed this statement incorrectly, ten
individuals (16%) left the sentence blank.
Authorities in the area of infant nutrition
speculate that the inclusion of high protein solid foods
in diets of breast and formula fed babies differ (Andrew,
et al., 1981; Fomon, et al., 1979).
If an infant begins
solid foods while being breast fed high protein foods
should be included in his/her diet.
However, of the 40
mothers (67%) who were nursing at the onset of beikost
feeding, 24
(60%) were not told to give their infants high
protein density foods.
Three (7%) mothers were informed
of this diet modification and thirteen (33%) had infants
who were not yet on solid foods.
On the other hand, it
is not necessary to include solid foods of high protein
value when the child is formula fed.
Twenty (33%) of the
infants in this study were formula fed at the time when
solid foods were introduced, 13 (65%) of these mothers
were not told of this dietary measure.
Seven (35%) of the
mothers stated that they were aware that it wasn't necessary to include high protein foods because their child
was on a commercially prepared formula.
Six of the most frequently mentioned food items
associated with allergies in infants were cow's milk, eggs,
citrus fruits, wheat, chocolate and berries.
Cow's milk
was listed by 43 (72%) of the mothers, eggs by 32 (53%),
38
citrus fruits 20 (33%), wheat 12 (20%} chocolate 5 (8%),
and berries by 5 (8%).
The foods indicated by the mothers
as being linked to the causes of food sensitivities, correlates with literature findings
(Bordeaux, 1982).
Twenty
(33%} of the mothers responded to this question with food
items not commonly linked to infant allergies.
Thirty-three (55%) of the mothers had not had any
nutrition courses in school, 20 (35%) had one and seven
(12%) had between two and four.
When asked the highest
grade completed, a total of 39 (65%) reported four years
of college or more.
Fourteen (23%) went through one to
three years of college and only six mothers (10%) reported
high school graduation only.
One person (2%) did not com-
plete this question.
In the last section of nutrition knowledge
assessment, fourteen statements were presented and mothers
were asked to agree or disagree with them, or indicate if
they didn't know.
Sixty (100%) of the mothers agreed
that an adult's attitude toward food influences an infant's attitude.
Fifty (83%) disagreed with the statement
regarding the implementation of rewarding good behavior
with favorite foods, seven (12%) agreed with this theory
and three (5%) didn't know.
Mothers were generally in
agreement with the Committee on Nutrition (1976) which
39
states that foods should not be used as a substitute for
emotional deprivation.
Thirty-three (55%) of the mothers supported the
results of studies conducted by Grunwaldt, et al.
(1960)
and Guthrie (1966) which concluded that there was no statistical correlation between feeding solid foods and uninterrupted night sleeping.
However, 17 (28%) noted late
night feedings were successful and 10 (17%) didn't know.
Fifty-eight (97%) of the respondents were in
agreement with the recommendations of Fomon, et al.
(1979)
that an infant should not be forced to finish the "last
drop of milk in a bottle" to assure that he/she has had
enough.
Only two mothers (3%) said that this practice
was advisable.
Ninety percent were in agreement that letting a
child sleep with a bottle of milk or juice can cause dental caries (Driggers, 1980).
Two (3%) mothers did not
agree with this phenomena and four (7%) didn't know that
bedtime bottle feeding increased the risk of dental
disease.
More mothers (80%) complied with their
pediatrician's recommendations, than the number of
mothers who said they received information and guidance
on infant feeding from their pediatrician, 32 (53%).
There is a discrepancy between pediatrician and patient
input/output.
40
All (100%) mothers understood that the best method
of identifying food allergies was to introduce foods
singly rather than in a mixed dish.
Half of the subjects (50%) knew that reducing
diets containing skim milk were inappropriate measures to
battle excessive infant weight gain.
Seventeen (28%)
mothers did not know that using skim milk or decreasing
calorie content of an infant's diet were unsatisfactory
methods of tailoring weight gain.
A fourth of the mothers
(22%) did not know that there could be risks involved with
weight reduction and/or skim milk diets in infancy.
Cur-
rent literature findings reveal that a practical treatment
of infant excessive weight gain is the slowing down of the
rate of weight gain in proportion to the infant's linear
growth.
Actual weight loss should be avoided and the use
of skim milk may lead to eventual health jeopardy if the
child contracts a prolonged illness (Fomon, et al., 1977).
It is correct that homemade foods often contribute
more calories to the diet than their commercial counterparts.
The latter contain more water and less fat (ESPGAN
Committee on Nutrition, 1981).
Results show that 41 (69%)
of the mothers did not know this, two (3%) did know this
fact, and 17 (28%) were undecided.
Half of the mothers (52%) disagreed with the
statement that by eight or nine months normal healthy
infants have the ability to eat almost all family foods
41
(Williams, 1977).
Only 16 (26%) of the mothers agreed
that with minor alterations, family foods can be consumed
by an infant before 12 months, 13 (22%) did not know.
Half of the mothers (53%) indicated that an infant
does not need teeth to eat solid foods, that they can do
an adequate job "gumming" their meals.
This agrees with
literature findings which stated that foods can adequately
be chewed with the gums (Lansky, 1976).
Seventeen (28%)
disagreed and felt that infants need teeth to chew their
foods and 11 (18%) didn't know.
The long term development of eating habits will be
affected by practices followed in infancy (Woodruff, 1978).
This idea was accepted by 52 (87%) of the mothers participating in the study.
Five (8%) didn't feel that their
infants eating patterns during their first twelve months
were critical to the future development of consumption
patterns.
Three (5%) mothers did not know.
The need for iron in the diets of infants has been
stressed by infant nutritionists.
The use of dry com-
mercially prepared iron-fortified infant cereals is recommended as a source of this mineral for all children
until at least 18 months of age (Fomon, et al., 1979;
Yeung, et al., 1981).
In this study only 11 (18%) of the
mothers knew this, 49 (82%) did not know that infant
cereals were good sources of iron.
CHAPTER 5
SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS
This study focused on the current knowledge of
'
mothers with regard to introducing solid foods to their
infants.
Feeding practices and nutrition knowledge were
assessed to determine a mother's needs and awareness in
this area of infant nutrition.
Summary and Conclusions
First-time mothers attending established motherinfant classes in the greater Los Angeles area were asked
to complete a questionnaire.
The data from the survey
were compiled and analyzed on a
f~equency
and percentage
basis.
The results showed that a large percentage of
the mothers were college educated, either completing
undergraduate school or having entered school at the
graduate level.
However, a great portion of the mothers
never had a nutrition class during their educational
career.
The absence of formal nutrition training re-
vealed that mothers' depend on their pediatrician or
printed media for nutrition information.
Almost all
/mothers expressed compliance with what their doctor said
42
43
but not all were satisfied with the amount of information
given.
Results indicated that in the area of psychosocial aspects of food, mothers knew that food practices
followed in infancy lay the foundation for future health
and eating habits.
They also knew that their own attitude
toward a particular food influences their infants' attitude.
The use of food as a reward was labeled a negative
practice by the majority of mothers.
Whatever the orig-
inal source of this information, mothers knew these concepts.
Several other areas where the mothers correctly
completed the questionnaire follow.
The fact that they
know that fat, protein and carbohydrates provided calories
to body was evident.
Mothers also made a distinction be-
tween high nutrient density and low nutrient density
foods.
The foods commonly associated with allergies were
frequently identified as eggs, cow's milk and citrus
fruits.
To assure proper detection of an allergenic food,
all mothers knew to introduce only single (not multiple)
foods at a given time.
Mothers were well informed that late night
feedings will not help their infant sleep through the
night.
They also knew the link between dental caries
development and drinking milk or juice from a bottle
prior to and during sleep.
44
Two unsafe tools often used in decreasing the
weight of an infant are the use of skim milk and reducing
diets.
Half of the mothers were not aware of the risks
involved in these two measures of weight control.
It is possible that mothers of today are preparing
their own baby food at home, as there were no clear-cut
answers to any of the questions regarding commercially
prepared foods by the mothers in the study.
As a conse-
quence, they did not use (or were not advised to use) the
commercially prepared baby cereals which are rich sources
of iron.
The onset of solid food feeding was generally
prompted by the infant's age and not by developmental
readiness as suggested in the literature.
Age of intro-
duction for beikost was most commonly established by
mothers as:
four to six months for (semi) solid foods,
seven to eight months for finger foods and nine to twelve
months for table foods.
During the four to six month per-
iod, mothers were not informed of the important difference
between the quantity of protein foods needed for formula
fed vs. breast fed infants.
All mothers, regardless of
the type of milk consumed by their infant, introduced
foods in the sequence of cereals, fruits, vegetables
and meats.
When asked in subsequent questions about family
(table) foods, mothers contradicted their first response
45
of beginning these food types between nine and twelve
months.
The mothers said infants did not have the ability
to eat family foods at eight or nine months.
Yet they
agreed that infants can adequately gum foods without
teeth.
There was a contradiction within the sample.
The majority of mothers were informed on the
,. issues
of infant nutrition and general nutrition.
There
were some gaps in their knowledge of common food and
nutrition practices with regard to infants.
The variety
of foods their infants were eating and the overall understanding of the con.cepts
presented leads the researcher
to believe the sample infants are on an appropriate beginning to a healthy future.
Recommendations for Further Study
Further research should be done to survey other
socioeconomic groups of mothers.
Fathers and other care-
givers (e.g., day care operators) might also be a desirable population to assess for their knowledge of infant
feeding.
A study to compare first-time mothers and mothers
of more than one child might provide different results.
In addition, it would be interesting to study nutrition
knowledge and practices of mothers with high risk infants.
46
Lastly, in depth research could be undertaken to
see if what mothers say that they do and know matches
their actual infant feeding practices.
LIST OF REFERENCES
American Academy of Pediatrics, Committee on Nutrition.
"On the Feeding of Supplemental Foods to Infants."
Pediatrics, 65(6) :1178-1181. June, 1980.
Andrew, Elizabeth M., Katherine L. Clancy, and Marcella G.
Katz.
"Sources of Kilocalories and Macronutrients in
the Infant Diet." Journal of the American Dietetic
Association, 79(2) :131-139. August, 1981.
Arnon, Stephens., and others.
"Honey and Other
Environmental Risk Factors for Infant Botulism."
The Journal of Pediatrics, 94(2) :331-338. February,
1979.
Barness, Lewis A.
"Feeding Children I.
Infant
Nutrition." Journal of the Florida Medical
Association, 66(4) :443-8. April, 1979.
Bordeaux, Dean R., and others.
"Infant Nutrition."
The Journal of Family Practice, 14(1) :145-150. 1982.
Butler, Allan M., and others.
"Trends in the Early
Feeding of Supplementary Foods to Infants."
Quarterly Review of Pediatrics, 9(2) :63-87. May, 1954.
Caplan, Frank. The First Twelve Months of Life.
York: Grosset & Dunlap, 1973.
New
Committee on Nutrition.
"Iron Supplementation for
Infants." Pediatrics, 58(5) :765-768. November, 1976.
Crummette, Beauty D., and Mary T. Munton.
"Mother's
Decisions about Infant Nutrition." Pediatric Nursing,
6(6) :16-9. November-December, 1980.
Dallman, P. R.
"Inhibition of Iron Absorption by Certain
Foods." American Journal of Diseases in Children,
134(5) :453-4. May, 1980.
Deeming, Susan B. and Charles W. Weber.
"Trace Minerals
in Commercially Prepared Baby Foods." Journal of the
American Dietetic Association, 75:149-151. August,
1979.
Driggers, David A.
"Infant Nutrition Made Simple."
American Family Physician, 22 ( 4) :113-6. October, 198 0.
47
48
Endres, J. B., and R. E. Rockwell. Food, Nutrition and
the Young Child. St. Louis: The C. V. Mosby Company,
1980.
ESPGAN Committee on Nutrition. "Guidelines on Infant
Nutrition. II. Recommendations for the Composition
of Follow-up Formula and Beikost." Acta Paediatrica
of Scandinavica, 287:1-25. 1981.
Filer, Lloyd J., Jr.
"Early Nutrition: Its Long-Term
Role." Hospital Practice, 87-95. February, 1978.
Fomon, Samuel J.
Infant Nutrition.
W. B. Saunders Company, 1974.
Philadelphia:
"What are Infants Fed in the United States?"
Pediatrics, 56(3):350-354. September, 1975.
, and others.
"Acceptance of Unsalted Strained
Foods by Normal Infants." The Journal of Pediatrics,
76(2) :242-246. February, 1970.
---=--=---.
---:------,::-
Normal
1979.
, and others.
"Recommendations for Feeding
Infants~~
Pediatrics, 63(1) :52-59. January,
, and others.
"Skim Milk in Infant Feeding."
---:A:-c-t=-a-=Paediatrica of Scandinavica, 66:17-30. 1977.
Green, L. S., and F. E. Johnston. Social and Biological
Predictors of Nutritional Status, Physical Growth,
and Neurological Development. New York: Academic
Press, 1980. ·
Grunwaldt, Edgar, and others.
"The Onset of Sleeping
Through the Night in Infancy." Pediatrics, 26:667668. October, 1960.
Guthrie, Helen A.
"Effect of Early Feeding of Solid
Foods on Nutritive Intake of Infants." Pediatrics,
38(5) :879-885. November, 1966.
Hamilton, E. M. N., and E. N. Whitney. Nutrition Concepts
and Controversies. St. Paul: West Publishing
Company, 1982.
Harland, Barbara F., and others.
"Calcium, Phosphorus,
Iron, Iodine, and Zinc in the 'Total Diet'." Journal
of the American Dietetic Association, 77(1) :16-20.
July, 1977.
49
Health Learning Systems, Inc.
"Infant Nutrition
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Heslin, Jo-Ann, and others.
your Baby's First Year.
Co. , 198 0.
No-nonsense Nutrition for
Toronto: CBI Publishing
Himes, John H.
"Infant Feeding Practices and Obesity."
Journal of the American Dietetic Association, 75(2):
122-125. August, 1979.
"Introduction of Beikost."
September, 1979.
Pediatrics, 64(3) :388.
Kirk, T. R.
"Appraisal of the Effectiveness of Nutrition
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Minnesota:
Your Baby & Child.
New York:
Alfred A.
Markesbery, Barbara A., and Wendy M. Wong.
"Watching
Baby's Diet: A Professional and Parental Guide."
American Journal of Maternal Child Nursing, 4:177-180.
May-June, 1979.
Maslansky, Ethel, and others.
"Survey of Infant Feeding
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780-785. August, 1974.
McDonald, Linda.
Instant Baby Food. Pasadena,
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Morse, Winifred and others.
"Mothers' Compliance with
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Journal of the American Dietetic Association, 75:
140-147. August, 1979.
"Nursing Bottle Caries."
May, 1977.
Pediatrics, 59(5) :777-778.
"Nutritional Adequacy of Breast Milk."
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The
APPENDICES
51
"'
(kg)
.-t
0
N
(lbs)
0
.-t
(em)
I,Q
M
I,Q
r--
CX)
N
N
0'1
3:
.
I=
+l
..,.
.I(
.
+l
(in)
0'1
.I(
X
X
N
0
Protein (g)
. .
N
N
0
N
..,. ..,.
0
0
(RE) Vitamin A
(llg) Vitamin D
0
CX)
"'
.-t
<
Q
ll::
tl)
><
~
Q
z
w
c..
p..
<
0
.-t
M
..,.
(mg) Vitamin E
on
on
M
M
(mg) Vitamin
. .
..,.
. .
w
<
0
.-t
u
z
<
~
M
on
0
0
0
0
I,Q
CX)
(mg) Thiamin
I,Q
..::1
..::1
<
><
c
(mg) Riboflavin
(mg equiv.) Niacin
ll::
<
E-t
M
I,Q
~
0
0
(mg) Vitamin B6
..,.
(llg) Folacin
w
. .
Q
Q
on
0
w
M
Q
z
w
I!0
u
w
ll::
.
on
on
0
.-t
(ll g) Vitamin Bl2
0
..,.0
(mg) Calcium
I,Q
M
on
..,.
I,Q
N
M
0
0
r--
(mg) Magnesium
0
on
0
.-t
.-t
on
(mg) Iron
M
on
(mg) Zinc
..,.
0
(\.!g) Iodine
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. .
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on
0
c
0
.....
0
.-t
I
~
0
+l
Ill
c
(mg) Phosphorus
I
on
0
r
Age (Years)
II
52
APPENDIX B
Location
ID
QUESTIONNAIRE
Please write in the requested information or place a
check mark in the appropriate space.
1.
Relationship to child:
Mother
Other,
Describe:
2.
Child's birthdate:
3.
Child's sex:
4.
Does child have any diagnosed medical problems?
No
Female
Male
Yes
If yes, please explain
5.
Was child diagnosed as premature at birth?
Yes
6.
No
Does your child visit a pediatrician for well-baby
check-ups?
No
Yes
If yes, approximately how often?
Once a month
Every 2-3 months
Every 6 months
Other
Explain
53
54
7.
Do you have any other children living at home?
Yes
No
How many?
Feeding Practices
Please answer the following questions regarding your
feeding practices.
8.
What has most influenced your infant feeding
practices?
(Rank in order with 1 being most influ-
ential, 8 being least influential).
Printed media (books, magazines, etc.)
School, educational background
Radio, television
Past experience
Pediatrician
Other health professional
Friends and relatives
Other
9.
Which statement best describes your method of meal
planning for your infant (check only one).
My child eats whenever she/he is hungry
I adhere to a rigid schedule of mealtimes
I follow a regular pattern of feeding
breakfast, lunch, dinner and snacks
Every day is different, mealtimes are
dependent on the day's routines.
Comments:
55
10.
Is your infant eating solid foods
milk or formula)?
Yes
(foods other than
No
At what age did you begin them?
Before three months
Between 4 and 6 months
Between 7 and 8 months
Between 9 and 12 months
After 12 months
11.
At what age does your
~ediatrician
recommend
begining solid foods?
Months
12.
I don't know
Which of the following factors did you consider
when it was time to introduce solid foods?
(Check
as many items as are applicable.)
Age
Sleeping habits
Developmentally ready (i.e., able to sit,
able to express hunger and satiety)
Advice from family or friends
Fussiness between milk feedings
Other
13.
What food groups is she/he using foods from today?
---
Cereals
Fruits
Meats
Other
Vegetables
56
14.
Is/was there a sequence in the order of foods
introduced?
Yes
No.
If yes, number the order followed.
Cereals
Fruits
______ Vegetables
Meats
15.
Is you infant eating finger foods (e.g., crackers,
toast, vegetables, fruits, etc.)?
Yes
No
At approximately what age did you begin introducing
these into his/her diet?
Before three months
Between 4 and 6 months
Between 7 and 8 months
Between 9 and 12 months
After 12 months
16.
Is you infant eating table foods?
Yes
No
At approximately what age did you begin giving
him/her family foods from the table?
Before three months
Between 4 and 6 months
Between 7 and 8 months
Between 9 and 12 months
After 12 months
57
17.
Please list a few foods your infant eats and enjoys:
18.
Did you ever feed your baby cereal in an infant
feeder (bottle)?
19.
Yes
No
To date, have you generally complied with what your
pediatrician has recommended for feeding your
infant?
He/she hasn't given me enough information
to follow
Yes
No.
If no, what major differences have
you practiced?
Nutrition Assessment
20.
All the essential nutrients fall into one of six
categories:
water, fat, protein, carbohydrate,
vitamins, minerals.
Circle the three that provide calories to the body.
21.
The commercially prepared infant food which is a
significant source of iron for a baby is (choose
one)
Meats
Cereals
Fruits
58
22.
After they are opened, commercially prepared foods
can be stored in the refrigerator for as long as:
One week
24-48 hours
Indefinitely
I don't know
23.
A low nutrient density food is one which contains
---
More
Less) calories in relation to
the nutrients it contains.
24.
If you began solids while your child was being
breast fed, were you informed that it was necessary
to include foods of high protein content in his/her
diet?
Yes
No
Not applicable
25.
If you began solids while your child was being fed
formula or cow's milk, were you informed that additional foods of high protein content were not necessary to include in his/her diet?
Yes
No
Not applicable
59
26.
Please list three foods most commonly associated
with allergies in infants.
27.
How many courses in school have you had in nutrition?
----,--
0,
- - -1, - - -2, - - -3' - - -4, - - -5,
More than 5
28.
Please circle the highest grade you completed.
Elementary:
1
2
3
4
High School:
9
10
11
12
College:
1
2
3
4
5
6
7
8
5+
Please indicate if you either agree or disagree with the
following statements.
Check "I Don't Know" if you are
neutral.
Agree
29.
An adult's attitude
toward food influences
an infant's attitude.
30.
Favorite foods are a
great reward for your
baby's good behavior.
31.
Feeding an infant late
in the evening will help
him/her sleep through
the night.
Disagree
I Don't
know
60
Agree
32.
Encouraging a baby to
finish the last drop of
milk in a bottle is the
best way to know she's
had enough.
33.
Letting the child
sleep with a bottle of
milk or juice can cause
dental caries.
34.
My doctor has given me
little information and
guidance on infant
feeding.
35.
To identify food
allergies it is best
to introduce only
single (not multiple)
foods at a time.
36.
Reducing diets and
using skim milk are
two satisfactory
measures to combat
excessive overweight
in infancy.
37.
Homemade foods have
more calories than
their commercially
prepared counterparts.
38.
At eight or nine
months, normal healthy
infants have the ability
to eat almost all family
foods.
39.
An infant does not
need teeth to eat
solid foods, many
foods can be adequately chewed with
the gums.
Disagree
I Don't
know
61
Agree
40.
Future eating habits
will not be affected
from practices followed in infancy.
41.
Dry cereals prepared
commercially for
infants should be a
part of their diet
until 18 months of
age.
Disagree
I Don't
Know