The Relationships of Maternal Perceptions, Psychosocial, and Sociodemographic Factors with Complementary Infant Feeding Practices

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By

Michelle Ann Dorsey Graf

Dissertation

Submitted to the Faculty of the Graduate School of Vanderbilt University

in partial fulfillment of the requirements for the degree of

DOCTOR OF PHILOSOPHY in

Nursing Science December 18, 2021 Nashville, Tennessee

Approved:

Sharon M Karp, PhD, APRN, CPNP-PC Mary S. Dietrich, PhD, MS

Melanie Lutenbacher, PhD, MSN, RN, FAAN Heather Wasser, PhD, MPH, RD

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This work is dedicated to the mothers and children for whom I hope this research will benefit, to my parents who instilled in me a love of learning and inquiry, to my husband, Brian, who offered

unwavering support and encouragement throughout this process, and to my children, Jason, and Eliza, who inspired me to do my best work.

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ACKNOWLEDGEMENTS

To my advisor and committee chair, Dr. Sharon Karp, thank you for guiding and encouraging me over the last six years. I am beyond grateful for the steady support and

mentorship you provided throughout the doctoral program. This would not have been possible without you.

A special thanks to my committee members, Drs. Melanie Lutenbacher, Mary Dietrich, and Heather Wasser for your commitments of time and energy to my research. It has been a true pleasure working with each of you. To the faculty and mentors at Vanderbilt University School of Nursing, thank you for giving me the foundation needed to reach the finish line.

I am exceptionally grateful for the unwavering support of my husband, Brian Graf, who encouraged me during the most frustrating setbacks, and celebrated with me during the most exciting achievements of my educational journey. I am also thankful for my children, Jason, and Eliza, who were born during this endeavor, inspired many of my research questions, and

provided an entirely new perspective on motherhood and balance. And finally, thank you to my parents, who first inspired my love of learning.

This publication was supported by CTSA award Nos. UL1TR002243 and UL1TR000445 from the National Center for Advancing Translational Sciences, a Sigma Theta Tau International Iota Chapter scholarship (October 2018), and the Vanderbilt University School of Nursing (VUSN). Its contents are solely the responsibility of the authors and do not necessarily represent official views of the National Center for Advancing Translational Sciences, the National

Institutes of Health, Sigma Theta Tau International, or VUSN.

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REFERENCES………...78

APPENDIX Appendix A. Consolidated Criteria for Reporting Qualitative Studies………...87

Appendix B. Interview Questions Guide……….89

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LIST OF TABLES

Table Page

2-1 Sample Hierarchical Coding System………...18 3-1 Summary of Personal and Sociodemographic Characteristics………....40 3-2 Complementary Feeding Practices by Infant Age………...42 3-3 Complementary Feeding Priorities from the Adapted Food Choice Questionnaire,

by Infant Age……….44 4-1 Descriptive Summary of Sample Personal, Sociodemographic, and Psychosocial Factors, and Allergenic Food Introduction...……….…..55 4-2 Introduction of Allergenic Foods by Participant Race Groups...………57 4-3 Summary of Unadjusted Associations of Maternal Personal, Sociodemographic, and

Psychosocial Factors with Introduction of Each of the Allergenic Foods ..………..59 4-4 Summary of Adjusted Associations of Maternal Personal, Sociodemographic, and

Psychosocial Factors with Introduction of Each of the Allergenic Foods..………..61 4-5 Number of Allergenic Foods Introduced……….………...62

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LIST OF FIGURES

Figure Page

1-1 Graf Complementary Feeding Practices Model ………...6 2-1 Complementary Feeding: Perceived Threats and Corresponding Strategies…………..……20 3-1 Frequency of Allergenic Food Exposure by Infant Age………..43 3-2 Frequency of Complementary Feeding Perceived Threats, by Infant Age……….44 5-1 A Model of Maternal Factors and Complementary Feeding Practices………...72

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1 CHAPTER 1

INTRODUCTION AND BACKGROUND

Overview

This doctoral research explores maternal perceptions about complementary feeding practices (CFP) and relationships of maternal perceptions and personal, sociodemographic, and psychosocial factors with CFP. A majority of prior CFP research has focused on the timing and type of complementary food introduction; however, research related to other important CFP is limited. Furthermore, although research has shown relationships among health beliefs and many behaviors, research exploring maternal decision-making related to CFP is limited and

preliminary.

Statement of the Problem

Some adverse childhood nutrition related health outcomes, such as childhood overweight or obesity and food allergies are on the rise in the United States (US) and other high-income countries. Food experiences during the first two years of life lay one pathway for risk of and/or protection from these conditions.^{1, 2} In infancy, a transitional dietary period known as

complementary feeding occurs, during which an infant progresses from consuming a diet

consisting exclusively of breastmilk or formula, to one of diverse foods and textures.³ Some CFP (i.e., the methods a caregiver uses during this transition), such as the timing and type of

complementary food introduction, lead to dietary trends and are associated with increased risk for overweight/obesity and food allergies. ^4-13 However, there is limited data for other important CFP, such as allergenic food exposure, spacing of new food introduction, feeding method, and usual texture intake, which makes studying relationships of these CFP with health outcomes

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difficult. Furthermore, evidence suggests a relationship of a mother’s personal and

environmental factors with her selected infant feeding practices (i.e., breastfeeding initiation and duration, and timing of complementary food introduction). ^14-29 However, research examining maternal decision-making related to other CFP is limited. A better understanding of the relationships of maternal factors with CFP has the potential to identify mothers and infants at risk of suboptimal CFP and undergird the development of interventions that can delay and/or prevent the development of adverse nutrition related health outcomes.

Purpose of the Study and Research Questions

The purpose of this exploratory sequential mixed methods two phase study was to explore maternal perceptions about CFP and relationships of maternal perceptions and personal, sociodemographic and psychosocial factors with CFP. The overall goals were to: 1) increase knowledge of maternal perceptions related to CFP, 2) establish a preliminary understanding of the relationships of maternal factors with CFP, and 3) lay a strong foundation for the future development of a psychometric tool to measure maternal priorities related to CFP. The following research questions guided this work:

1) What are maternal perceptions (i.e., perceived threats, perceived benefits, and priorities) of complementary feeding (Goals 1 and 3)

2) What are the relationships of maternal perceptions with CFP? (Goal 2)

3) What are the relationships of maternal psychosocial or sociodemographic factors with CFP? (Goal 2)

Phase one addressed research questions one and two. It included pilot testing of a questionnaire and qualitative methods, including private interviews of 27 mothers to explore complementary perceived threats priorities, and practices. Based on findings from phase one, the

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questionnaire was refined and finalized. For phase two, the questionnaire was administered via a web-based survey to a sample of 400 mothers from across the US. Quantitative data analyses addressed research question three.

Significance

The Magnitude of the Problem of Adverse Nutrition Related Health Outcomes in US children In the United States (US) and other high income countries, advances in nutrition science over the last 100 years have led to significant decreases in many childhood nutrition related adverse health outcomes, such as scurvy, beriberi, and iron deficiency anemia.³⁰ However, other adverse childhood nutrition related health outcomes, including childhood overweight/obesity continue to rise.^{31, 32} In the US, childhood obesity has more than tripled over the last 30 years, with an estimated 19.3% of 2-19-year-olds found to be obese in the 2017-2018 time period.³² Food allergies affect an estimated 7-10% of the United States (US) population, with steady increases over the last 20 years.^{31, 33-38}. Both childhood obesity and foods allergies are associated with physical, emotional and financial hardships for affected children and their caregivers,^39-48 and both tend to persist across the lifespan.^{34, 49, 50} Furthermore, both conditions

disproportionately affect Black/African American (AA) and Hispanic/Latinx (LA) children, compared to White/Caucasian children. ^{34, 51-54} The rise in adverse nutrition related health

outcomes and major differences in prevalence rates indicate a public health issue needing further investigation.

Relationships of Infant Feeding Practices with Nutrition Related Health Outcomes While the underlying mechanisms for both childhood obesity and food allergies are not entirely clear, evidence suggests that early infant feeding experiences create one pathway towards childhood nutrition related health outcomes.49, 50, 55-57 For example, compared to bottle

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feeding, breastfeeding is associated with a significantly lower risk of obesity, food allergies, eczema, otitis media, gastroenteritis, and sudden infant death syndrome.⁵⁸ Similarly, parental feeding styles, such as authoritarian, permissive, or indulgent, are also associated with growth and nutritional issues including pickiness, dietary quality, and childhood overweight/obesity.^{59, 60} Introduction of complementary foods prior to 4 months of age, and feeding of juice, nutrient- poor snacks and sweets are associated with excessive weight gain and risk for obesity throughout childhood.^4-6 Finally, introduction of allergenic foods early in the period of complementary feeding (i.e., around 4-6 months old) has been shown to decrease the risk of developing a food allergy.^7-13

Current Complementary Feeding Guidelines

Based on the growing body of evidence for the relationships of CFP with health outcomes,49, 50, 55-57 Dietary Guidelines for American (DGA) released its first recommendations for complementary feeding for infants 0-23 months old, in December 2020.⁶¹ The new

guidelines recommend beginning complementary feeding around 6 months old, and beginning with spoon-feeding of pureed, nutrient-dense foods. DGA also recommend introduction of allergenic foods around 6 months old. For food spacing, the DGA provide no suggestions for the number of days between new foods, and rather encourage feeding of a variety of foods,⁶¹

whereas former CFP guidelines from American Academy of Pediatrics advised spacing of 3-5 days between new foods.⁶² Conceptually, these new recommendations can be divided into five sub-concepts: 1) timing and type of complementary food introduction, 2) feeding method (i.e., spoon-feeding vs. self-feeding), 3) usual texture intake, 4) spacing of new food introduction, and 5) allergenic food exposure.⁶¹

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Opportunities to Improve Scientific Knowledge

When reviewing prior complementary feeding research related to the sub-concepts, we identified a significant gap. A majority of CFP research has focused on only one of the CFP sub- concepts: timing and type of complementary food introduction.^4-6 Although the DGA is a long- awaited clinical tool to guide complementary feeding, there are significant gaps in our

understanding of maternal decision-making related to CFP. A majority maternal decision-making work has focused on breastfeeding or on CFP in low-income countries, ^{23-28, 63} but decision- making factors related to CFP in a high-income country are likely to be quite different.

Guidelines alone are not likely to be effective without addressing how mothers, who make the majority of complementary feeding decisions,^{25, 64} decide about how and what to feed their infants. Due to the limited research related to maternal complementary feeding decision-making in high income countries, we utilized prominent theoretical decision-making models to guide our study.

Theoretical Model

Figure 1 illustrates the Graf Complementary Feeding Practices Model, which guided this study and was derived from a review of the relevant literature and two prominent evidence-based theories: Mercer’s Becoming a Mother Theory (BAMT),⁶⁵ and the Health Belief Model

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relevant to the study, yet neither alone allowed for adequate assessment of the relationships among maternal perceptions and personal, sociodemographic, and

psychosocial factors and CFP.

The relationships of interest for this study are represented by dashed lines.

The Graf Complementary Feeding Practices Model proposes that a mother’s perceptions and psychosocial and sociodemographic factors influence CFP, which lead to infant nutrition and feeding related trends, and subsequent childhood nutrition related health outcomes. Drawing from Mercer’s BAMT, the foundation of the model is the relationship between the mother and infant in which maternal factors influence infant health outcomes;⁶⁵ however, the BAMT does not account for health behaviors, such as CFP, some of which have been shown to influence health outcomes.^4-13 In the Graf Complementary Feeding Practices Model, the hypothesized relationships of maternal factors with CFP are borrowed from the HBM, a prominent and well- tested decision-making model which suggests that an individual’s risk appraisal influences their behaviors.^{66, 67} Synthesizing the HBM with the BAMT, the Graf Complementary Feeding Practices Model hypothesizes that a mother’s psychosocial and personal/sociodemographic factors and perceptions (i.e., risk, benefits, and priorities) related to her infant’s health and safety

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(e.g., choking, food allergy, pickiness, and weight status) influence her CFP. Whereas BAMT suggests a bidirectional interaction between mother and infant, the Graf Conceptual Model draws from the HBM to propose a unidirectional relationship of maternal factors with CFP. Rather than occurring as an interactive process, the Graf Complementary Feeding Practices Model

hypothesizes that mothers likely make some decisions about how to feed their infant based on their risk/benefit perceptions, prior to initiating complementary feeding.

Review of Relevant Literature

Complementary Feeding Practices and Nutrition Related Health Outcomes Research suggests a relationship of CFP with nutrition related health outcomes; 4-6, 68, 69

however, gaps remain in our understanding of this relationship. A majority of CFP research has examined the timing and type of complementary food introduction and relationships with infant weight trajectories. ^4-6 However, the concept of CFP includes several other important sub-

concepts: spacing of new food introduction, feeding method, usual texture intake, and allergenic food exposure. Research of these CFP has been limited, with even less empiric evidence of relationships with nutrition related health outcomes.

For timing of complementary food introduction, two systematic reviews found evidence indicating that very early introduction of complementary foods at or before 4 months old,

increases the risk of childhood overweight throughout childhood.^{5, 6} Similarly, a 2019 large birth cohort study in the US found that introduction of complementary foods prior to 4 months old was associated with higher adiposity measurements (e.g., waist circumference, truncal fat mass, and subscapular and triceps skinfolds) in mid-childhood (mean= 7.9 years) and early adolescence (mean= 13.2 years).⁴ That same study found that the type of complementary food introduced

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prior to 4 months old (i.e., infant cereal and fruit juice, but not fruits or vegetables) was associated with higher adiposity measurements in mid-childhood and early adolescence.⁴

An analysis of the literature revealed gaps related to spacing of new food introduction (i.e., the number of days waited between introducing a new food). A 2020 study surveyed US pediatric healthcare providers about their recommendations on spacing of new food introduction and found the most common recommendation was to wait 3 or more days between offering new foods (38.6%);⁷⁰ however, a provider recommendation for spacing does not necessarily translate into maternal CFP. The Infant Feeding Practices Study II, a longitudinal birth cohort study in the US, collected information about a variety of infant feeding practices, one of which was spacing of new food introduction during complementary feeding.⁷¹ However, a review of the literature revealed no published descriptive summaries of spacing of new food introduction, nor statistical analyses of relationships with nutrition related health outcomes.

An emerging body of research has investigated feeding method (i.e., spoon-feeding, and self-feeding). Traditionally, complementary feeding begins with spoon-feeding administered by the parent; however, growing in popularity is a new approach known as baby led weaning (BLW), in which an infant self-feeds graspable foods.⁶⁸ A 2016 randomized controlled trial found no differences in choking between infants fed with a BLW and a traditional approach.⁷² Similarly, a 2017 review found some evidence suggesting that compared to traditional spoon- feeding, BLW may be associated with some nutrition related health outcomes, such as reduced pickiness and lower risk for obesity.⁶⁸ However, there were significant limitations of these studies, including self-report and retrospective design, self-selection, and inconsistencies in the definition of BLW, and the impact of BLW on health outcomes is therefore, unknown.⁶⁸

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Further review of the literature also revealed gaps in CFP research related to usual texture intake (e.g., pureed, cut-up/chunky, ground/lumpy, dry/crispy). One study developed and tested a measure of daily problems with texture in children’s feeding behavior and found associations of reports of texture problems with heavier weight status.⁶⁹ However, this study was conducted in a convenience sample of children with feeding difficulties, the majority of whom had

developmental disorders or special needs, and findings may be different in a sample of healthy infants whose parents were not seeking specialized healthcare services for feeding difficulties.

Research over the last 15 years has demonstrated that early exposure to allergenic foods around 6 months old is associated with lower risk of developing food allergy in children.^7-13 Missing from the literature are descriptive studies about prevalence and practices of allergenic food exposure in infancy.

Maternal Factors and Complementary Feeding Practices

Evidence also suggests relationships of maternal factors with infant feeding practices;

however, gaps also exist in these findings. ^14-28 A large body of evidence has shown maternal personal and sociodemographic (e.g., race, ethnicity, income, BMI, age, education, and parity) and psychosocial factors (e.g., anxiety and depressive symptoms) to be associated with

breastfeeding initiation and duration; ^14-20 however, factors impacting CFP may be quite different from breastfeeding, which heavily impacts a mother’s body and autonomy. Evidence has also suggested a relationship among maternal factors and one CFP: timing of complementary food introduction. ^{21, 22, 29} A cross-sectional study in Norway found relationships of maternal personal and sociodemographic factors (e.g., maternal age, education, income, and breastfeeding initiation and duration) with timing of complementary food introduction.²¹ A longitudinal birth-cohort study in primarily white, middle-class mother-infant dyads in Pennsylvania had similar findings,

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and also found maternal pre-pregnancy body mass index (BMI) to be a factor.²² Finally, a longitudinal birth cohort study in France found maternal BMI, age, parity, and breastfeeding duration to be associated with timing of complementary food introduction.²⁹ A potential

limitation of these studies was selection bias. Furthermore, there was limited sociodemographic diversity within these studies; however, findings were similar across studies, suggesting findings are generalizable across populations. Analysis of relationships of maternal factors with CFP other than timing of complementary food introduction is an identified gap in the literature.

Evidence also suggests a relationship between maternal perceptions and infant feeding practices.^23-28 Qualitative studies suggest that a mother’s perceptions of the risks and benefits of breastfeeding influence her decision to initiate and continue breastfeeding.^23-25 However,

maternal perceptions about breastfeeding, which also impact a mother’s body, may be quite different from CFP. Emerging but limited quantitative evidence reveals a potential relationship of maternal perceptions about infant well-being with only one CFP: timing of complementary food introduction.^26-28 Yet, significant gaps remain in fully understanding critical components of maternal decision-making related to CFP.

Dissertation Chapters

This project was conducted in two steps which are described in detail in each of the subsequent dissertation chapters. Chapter two describes the qualitative portion of the study that explored maternal perceptions related to CFP and how they influenced the strategies mothers used to introduce complementary foods to their infant. Chapter three is a descriptive summary of CFP used by mothers from across the US. Chapter four describes a portion of the quantitative analysis, which examined relationships of maternal personal, sociodemographic, and

psychosocial factors with allergenic food exposure. Taken as a whole, chapters two through four

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provide a new understanding of CFP and maternal factors influencing CFP. Chapter five summarizes main findings from the study and explains next steps for the relevant research trajectory.

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CHOKING, ALLERGIC REACTIONS, AND PICKINESS: A QUALITATIVE STUDY OF MATERNAL PERCEIVED THREATS AND RISK AVOIDANCE STRATEGIES DURING

COMPLEMENTARY FEEDING

This chapter reports the results of research questions #1 and #2, which were achieved through a qualitative study that explored maternal perceptions associated with complementary feeding and relationships of maternal perceptions and CFP. Specifically, this chapter presents maternal perceived threats associated with complementary feeding and the complementary feeding strategies mothers used to mitigate perceived threats for their infants. The results led to refinement of a quantitative questionnaire that would be used to subsequently measure maternal complementary feeding perceptions (i.e., perceived threats, perceived benefits, and priorities) and CFP.

Introduction

1The complementary feeding period is a brief, yet important developmental phase in which an infant transitions from a diet consisting exclusively of breastmilk or infant formula to one of diverse foods and textures.⁷³ Complementary feeding practices (CFP), such as the timing and type of complementary food introduction, have been found to influence the development of

1 Abbreviations: complementary feeding practices (CFP), American Academy of Pediatrics (AAP), American Academy of Allergy, Asthma and Immunology (AAAAI), Centers for Disease Control and Prevention (CDC), Supplemental Nutrition Assistance Program for Women Infants and Children (WIC), Dietary Guidelines for American (DGA), by COnsolidated criteria for REporting Qualitative research (COREQ), Institutional Review Board (IRB)

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dietary patterns, creating one pathway for growth and disease risk across the lifespan.2, 5, 59, 74-76

There are many professional recommendations about complementary feeding; yet, until recently, there were very few evidence-based guidelines.^77-80 In 2020, for the first time ever, the Dietary Guidelines for Americans (DGA) released focused dietary guidelines for feeding infants from birth to 23 months.⁶¹ These new guidelines provide an opportunity for researchers, educators, policy makers and healthcare providers to reassess former feeding recommendations and incorporate new evidence into practice.

According to key DGA complementary feeding guidelines, infants should exclusively consume breastmilk (or iron fortified infant formula if breastmilk is unavailable) until around six months, at which point they should also begin to consume a variety of nutrient dense

complementary foods.⁶¹ In addition, the DGA guidelines suggest that along with complementary foods, parents should offer potentially allergenic foods (e.g., peanut products, eggs, shellfish, milk products, tree nut products, wheat, fish, and soy), avoid unhealthy additives (e.g., sugar and sodium), strive for a healthy dietary pattern that includes foods from all food groups, and avoid foods with a high risk of choking.⁶¹

Clinicians have long anticipated these new guidelines, but mothers, who make most complementary feeding decisions, are not likely to adjust their CFP solely based on the release of new guidelines.^{25, 64} Historically, there has been a discrepancy between the limited professional guidelines available and maternal feeding practices.^{4, 81-83} Even with an ongoing 25-year

recommendation from the American Academy of Pediatrics (AAP) for exclusive breastfeeding from birth until around 6 months of life, only 25% of infants in the US are exclusively breastfed at 6 months.^81-83 The AAP also recommends waiting until around 6 months to introduce

complementary foods, but approximately 20% of US mothers introduce complementary feeding

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before 4 months.⁴ The DGA for infants is a welcome tool to guide complementary feeding, but to promote the healthiest CFP, we must consider how mothers make decisions about how and what to feed their infants during this period.⁶¹

Research investigating maternal decision-making processes for CFP has been limited to low- and middle-income countries.⁶³ In high-income countries, a large body of qualitative research has explored maternal decision-making related to breastfeeding.^23-25 Overall findings suggest that social support, social norms, and attitudes and beliefs about the health benefits, influence a mother’s decision to initiate and continue breastfeeding.^23-25 However, attitudes and beliefs about CFP are likely to be different than those for breastfeeding, which so strongly affects a mother’s body and autonomy.^23-25 Emerging but limited quantitative evidence reveals a

potential relationship of maternal attitudes and beliefs about fussiness, hunger or satiety, and sleep with only one CFP: timing of complementary food introduction.^26-28 Yet, significant gaps remain in fully understanding critical components of maternal decision-making related to CFP.

Decision-making models suggest that an individual’s attitudes, beliefs, and risk appraisal influence his/her behaviors.^{66, 67, 84} When these models are applied to the complementary feeding period, they suggest that a mother’s attitudes and beliefs about perceived threats and benefits related to health and safety (e.g. choking or food allergy) may influence how she feeds her infant.^{66, 67, 84} However, data supporting this relationship is limited and preliminary.^85-89 Therefore, this qualitative study aimed to identify mothers’ perceived threats surrounding complementary feeding and the complementary feeding strategies they used to mitigate perceived threats for their infants.

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Subjects and Setting

This qualitative study took place in the central, eastern United States between August and November 2019 and explored maternal perceived threats and strategies surrounding

complementary feeding. Data collection, coding, and analysis was guided by COnsolidated criteria for REporting Qualitative research (COREQ).⁹⁰ Supplementary File A includes the full COREQ checklist. The study team used purposive sampling to recruit a diverse sample with broad experiences of feeding across ethnic, educational, and socioeconomic backgrounds (n=27) until responses indicated data saturation. Multiple recruitment strategies were used, including a) in person recruitment and posted flyers in WIC clinics in local health departments, b) online recruitment via Craigslist volunteer advertisements, and c) posted flyers at community sites, including coffee shops, public libraries, restaurants, children’s bookstores and laundromats, Latino grocery stores and community boards in neighborhoods that are predominantly inhabited by minority families. Participants received a $25 gift card upon completion of one interview as compensation for their time.

Mothers were eligible to participate in one interview if they were: a) between 18 and 40- years-old, b) had at least one infant between 6 and 19-months-old, c) had the ability to read and speak English, d) and had no established relationship with the interviewer/PI. Mothers were ineligible to participate if their infant had a medical issue that could affect feeding (e.g., cleft lip/cleft palate, Down Syndrome, diagnosed food allergy, or metabolic disorder), or if the infant was born prior to 35 weeks estimated gestational age. One mother who contacted the PI was

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ineligible for participation (age of the infant >19 months). No one approached in person refused, nor was ineligible to participate, and no participants withdrew from the study after completing the eligibility screening.

Interview Guide

A semi-structured interview guide, based on a review of the literature and identified gaps, guided each interview. Six researchers with experience in maternal/child health, pediatrics, nutrition, public health, and qualitative methodologies reviewed and revised the interview guide to enhance rigor and trustworthiness of the results. Eight open-ended questions assessed the topical areas of: priorities, concerns, perceived benefits, and challenges. Maternal perceived threats and complementary feeding strategies related to each topic were explored with probes to further guide discussion. The interview guide was pilot tested with three mothers for clarity, question overlap and completeness. Their feedback was incorporated into the final guide. See Supplementary File B for a full copy of the interview guide.

Procedures

The [blinded] Institutional Review Board (IRB) and the [blinded] Department of Health IRB approved all study procedures (study numbers 201179 and 4027, respectively). Given the multiple recruitment strategies, mothers were either approached by the PI/first author (MG) and provided with a brief overview of the study, or they contacted the PI regarding their interest in the study. After explaining the purpose of the study and ensuring eligibility criteria, the PI/ and the mother agreed on the most convenient time and place to meet for the interview: a) a private WIC office immediately following her appointment, b) a private conference room at the public

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library, or c) privately from her home via videoconference. Only the mother, her child(ren), and the PI were present for the interview.

Each interview was led by the PI, who at the time of the study was a female Registered Nurse, Certified Family Nurse Practitioner, and a PhD candidate in nursing science, with training and experience in qualitative interviewing of mothers. For the interview, mothers met privately with the PI in person or face-to-face via a videoconferencing platform of their choice (e.g., FaceTime, Skype, or WhatsApp). Prior to the start of the interview, the PI reviewed the study purpose and procedures, obtained verbal and electronic informed consent, and advised each participant of her right to withdraw at any time. Prior to starting the study, participants reviewed and consented to participation on the study tablet or their personal device (e.g., smart phone, tablet, or laptop) using Research Electronic Data Capture (REDCap), a secure, web-based application for managing online databases. The PI began each interview with an introduction to explain her background, training, and reason for conducting the research, and to encourage the mother’s comfort. Following the introduction, she asked a series of open-ended questions with probes from the semi-structured interview guide. The PI recorded the interviews using two digital voice recorders. Following the interview, mothers completed a short demographic questionnaire on their personal device or study tablet. Interviews lasted between 10 and 30 minutes.

Data Analysis

Qualitative analysis of the interview responses was led by the PI (coder 1), in collaboration with an experienced qualitative researcher with a master’s degree in social

psychology (coder 2), and oversight from a senior psychologist, qualitative researcher. The team used inductive and deductive qualitative content analysis to interpret the interview data and to

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identify maternal perceived threats and complementary feeding strategies. The team submitted digital audio files of the completed interviews to a professional transcription service. After transcription, the team organized verbatim transcripts within Microsoft Excel 2018, by isolating individual statements; each statement was treated as a separate quote. Using an iterative,

inductive-deductive approach, and based on the study questions, interview guide, and assessment of the first four

interview transcripts, the two coders established a hierarchical coding system to organize the quotations. Table 2-1 provides an example of the codes,

categories, and descriptions from the hierarchical coding system.

For the initial four transcripts, the two coders

independently reviewed each quote and assigned relevant codes. The coders then met to resolve discrepancies in coding and to establish inter-rater agreement. For the remaining transcripts, the

Table 2-1. Sample Hierarchical Coding System

Code Category Description

7 Safety and health measures Discussed the measures taken to ensure her infant was safe and healthy

7.1 CPR certification Participant mentioned having CPR certification 7.2 Supervised while eating Participant mentioned remaining with child or

watching child while feeding

7.3 Single ingredient Participant introduces a one-ingredient food item as a safety measure

7.4 Repeat exposure Participant mentioned the importance of exposing the child to previously rejected foods multiple times 7.5 Offering in a specific order Participant mentioned offering foods in a specific

order at each meal

7.6 Tooth Development Participant mentioned teeth as a factor in deciding what foods to give to infant

7.7 Modeling Participant described modeling healthy eating or putting the infant at the table during family meals 7.8 Foods she avoids introducing Participant described foods she avoids giving to her

infant

7.8.1 Infant cereal Participant mentioned avoiding giving her infant, infant cereal

7.8.2 Allergenic foods Participant mentioned avoiding giving her infant allergenic foods (e.g., nuts, shellfish, eggs, etc.) 7.8.3 Commercially prepared purees Participant mentioned avoiding giving her infant

commercially prepared purees

7.8.4 Red meats Participant mentioned avoiding giving her infant red meats

7.8.5 Junk food/fast food Participant mentioned avoiding giving her infant junk food or fast food

7.8.6 Other Participant mentioned avoiding giving her infant

other foods

7.9 Introduce Allergenic foods Introduce allergenic foods as a safety measure 7.10 Food texture/consistency/size Mother expressed consideration of the food texture,

consistency, or size as a safety measure; or preparation (e.g., cutting into pieces)

7.11 Other Other strategy to ensure the safety and health of the infant

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PI used the coding system to identify the frequency of codes and to review quotes sorted by category, meeting weekly with the second coder to review findings and resolve any ambiguities.

Finally, after the coding process was complete, the two coders, along with the senior researcher, met to identify the major patterns in the data and generate analytical themes that represented the major findings from the dataset. The entire study team discussed and refined major themes and subthemes to optimize the analytic potential of the data. They then selected illustrative quotes to support the themes identified during the analysis.

Results

Participant Characteristics

The study sample consisted of 27 mothers. Most participants (n=21) enrolled from the community, with 6 mothers recruited from WIC Clinics. The median maternal age was 29.8 years (Interquartile Range (IQR) 27.8-34.7), with ages ranging from 22.3 to 40.7 years. The median age of the infant discussed in this study was 11.6 months (IQR 8.0-13.0) and ranged from 6.2 to 18.0 months. Participants reported a median of 16.0 years of education (IQR 13.0- 17.0), ranging from 7 to 20 years. Most participants were non-Hispanic/non-Latinx (92.6%) and Caucasian/white (57.5%); however, there was racial diversity among the sample. About one- third of participants identified as African American or black (30.8%), and the sample included some representation from Asian backgrounds (7.7%) and multiple races (3.8%). There was approximately the same number of low-income and high-income participants with 40% reporting an annual household income of $40,000 or less (the threshold for WIC eligibility in the state of recruitment), and 44% reporting $80,000 or more. Most participants (61.5%) had commercial, private, or military health insurance, while almost a third (30.8%) had state funded health insurance. Most mothers (77.8%) were married or living with a partner, were first-time mothers

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(63%), and breastfed their infant at the time of enrollment (66.7%). Over half of participants (52%) were unemployed.

Major Themes and Subthemes of Complementary Feeding Perceived Threats and Strategies

Three primary themes of maternal perceived threats related to complementary feeding emerged: 1) choking, 2) food allergy, and 3) pickiness. Within each of these major themes were subthemes that delineated mothers’ perceived threats and the specific and focused

complementary feeding strategies mothers used to approach each perceived threat (See Figure 2- 1). The perceived

threats were very similar across mothers;

however, mothers’

complementary feeding strategies varied. Each

major theme and subtheme is described bel ow along with illustrative statements presented in quotations. Each quote is followed by a “P,” with a number indicating the interview order of the participant and age of the infant. Ellipses are used within quotes to eliminate extraneous

information and ease readability.

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21 Perceived Threat of Choking.

Most mothers (n=23) identified choking on food as a major perceived threat during the complementary feeding period. One mother said, “every time she eats, I get worried she’s going to choke…” (P3-13 months). Several mothers (n=7) reported episodes in which their infant experienced a choking or near-choking event (e.g., coughing, choking, or gagging on foods), and discussed how they had adapted their complementary feeding strategies as a result. Mothers discussed various complementary feeding strategies they used to mitigate their perceived threat of choking, and two subthemes emerged: a) feeding with caution, and b) presenting the foods.

Feeding with Caution.

Many mothers reported using cautious or vigilant strategies to structure the

complementary feeding environment to lessen the perceived threat of their infant choking, or to respond optimally in the case of a choking event. Many mothers reported waiting for the

emergence of infant teeth to introduce complementary feeding. One mother said, “She only has a of couple teeth …, so I don't give her anything that causes her to…use her chewing” (P22-6 months). Also, to lessen the perceived threat of choking, and to respond appropriately if it occurred, many mothers mentioned attentively watching, observing, or remaining with their infant as they ate. One mother said “…when I give him food, I'm always there. I'm not in the kitchen trying to do something else. I'm there, right with him” (P19-12 months). Several mothers also discussed limiting the amount of food on their infant’s plate or tray. One mother explained,

“I've just been giving him…three or four…bite sized pieces, and then let him…feed himself…

because he's stuffed his mouth to the point of having to…stick my finger in there and pull it all out” (P20-13 months). To be prepared to best respond in the case of a choking event, several mothers reported taking infant safety and CPR courses.

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22 Presenting the Foods.

Most mothers discussed the strategies they used to decide how they prepared and offered complementary foods to mitigate their perceived threat of their infant choking. Many reported only feeding their infant pureed foods, and many even delayed advancing the texture of food from pureed foods to lumpy, mashed, or chopped foods. Speaking about her apprehension of feeding non-pureed foods, one mother said, “I'm kind of nervous… because I'm a first-time mom, so I don't want to mash up a banana and give it to him…What if he starts choking…” (P24-8 months). While transitioning their infant from pureed to more complex foods, many reported feeding simple, modified textures (e.g., softened, steamed, pre-chewed, ground, lumpy, chunky, or mashed foods). Many mothers also discussed slowly transitioning from least to most complex textures to give the infant time to adjust and avoid the perceived threat of choking. One mother explained, “In the beginning I…checked how he's…swallowing…, but once he was swallowing fine…, I…started to make the purees a little bit more chunky…It was puree, chunky puree, a little bit more chunky puree, …just eat whatever you want” (P19-12 months). As infants progressed to eating table foods, mothers reported cutting or chopping the food into small pieces to avoid choking. One mother explained that when she first started feeding her infant table foods, she

“started cutting up the banana and giving him small pieces of that” (Interview 11-11 months).

Paradoxically, some mothers discussed perceived threats that their infant would choke on small pieces, so they prepared larger items for them. One mother explained, “a lot of people say cut it into small pieces, but… I feel like she could choke more on that stuff. If I give her bread or something…I give her big pieces...” (P7-8 months). Most mothers noted they avoided “choking hazards,” like grapes, raisins, popcorn, nuts, beans, and hotdogs.

Perceived Threat of Allergic Reaction(s).

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A majority (n=23) of mothers described perceived threats (i.e., terrified, anxious, afraid, scared, worried, nervous, and concerned) of their infant experiencing an allergic reaction to foods during the complementary feeding period. One mother said, “I think the hardest part was just figuring…out… what's okay to give her … If she had an allergy, what would it look like?”

(P20-13 months). Perceived potential sources of an allergic reaction varied across mothers, with some related only to known highly allergenic foods (e.g., peanuts, eggs, or shellfish), but others afraid of reactions to any food. Mothers’ perceived threats about the possible severity of allergic reactions also varied, with some mothers believing a reaction would present as a topical skin rash or diarrhea, but many believing it would present as a severe and life-threatening emergency. One mother said “what if she just... throat closes up, stops breathing. Oh, my God, I was so scared”

(P21-11 months). Mothers’ complementary feeding perceived threats also related to the timing of onset of an allergic reaction after exposure to the source. Some mothers believed a reaction would occur suddenly and immediately after exposure, while others believed it could occur days later. Mothers used multiple complementary feeding strategies to mitigate the perceived threat of their infant experiencing an allergic reaction or to lessen their infant’s risk of major illness or death in the case of an allergic reaction. Strategies clustered into two subthemes: a) minimizing the risks, and b) preparing for an event.

Minimizing the Risks.

Some mothers approached their perceived threat of allergic reaction by avoiding highly allergenic foods, such as peanut products, shellfish, and eggs, and many waited for an optimal time and place to introduce them. One mother said, “we don't really give him any type of

shellfish right now…or peanut butter… because I don't know if he's allergic…I don't want him to breakout with an allergic reaction and us not be able to rush him to where he needs to go” (P11-

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11 months). Even when advised by their healthcare provider to introduce allergenic foods, some mothers opted to delay introducing them due to perceived threat of an allergic reaction. One mother explained, “the pediatrician did say…next month…when he's nine months…she wants us to have certain foods in him for allergies. So far, the only thing we did was peanut

butter…there's… nervousness if the baby…ate a food and he was allergic to it, what would I do?” (P24-8 months). Conversely, several mothers exposed their infants to allergenic foods early in the complementary feeding period to determine if their infant was allergic to a food, and to be prepared when they encountered that food in the future. One mother explained, “we have let her try eggs and dairy…fish and shrimp…, just in case... There are times where I know that she's probably going to be somewhere, and I would just hate…if she ate a cupcake and there were eggs in it and now, she's allergic and we didn't know that” (P16-12 months). Some mothers also exposed their infants to allergenic foods to reduce their likelihood of developing a food allergy. One mother explained, “We definitely have been…introducing to him all the allergenic foods. He had all the nuts…the shellfish and crab and…one evening…he had shrimp, crab and lobster” (P19-12 months).

Preparing for an Event.

To cope with their perceived threat of allergic reaction, many mothers noted how they prepared themselves to identify and handle a reaction if one occurred. Prior to initiating the transition to complementary feeding, many mothers collected information about allergic reactions from friends, family, healthcare providers, or the internet. Many mothers reported strategically introducing new foods, offering each slowly, over several days, and as single ingredients, to ensure their ability to identify the source in the case of an allergic reaction. One mother explained, “we'd do the carrots for three days…then the sweet potatoes for three days

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and so on...when we got comfortable with her not having an allergy… we'd start combining them or making sure we're only introducing one at a time…” (P13-6 months). Also, to ensure easy recognition of the source, some mothers used a method of monitoring, (i.e., keeping track of what the infant ate). One mother said, “I have a baby journal in case she has an allergic reaction to anything. Then I can go back and look and see” (P3-13 months). Like strategies to prepare for a choking event, several mothers completed medical training and preparation such as a CPR or first aid course to be able to recognize and respond to a potential allergic reaction quickly and effectively. One mother even mentioned purchasing a children’s antihistamine prior to starting complementary feeding to be prepared in the case of an allergic reaction.

Perceived Threat of Pickiness.

Emerging across all interviews were perceived threats that infants would develop pickiness about foods. Mothers’ described pickiness as an infant having strong food, flavor, or texture preferences, characterized by frequent refusals, limited acceptance, and difficulty

adjusting to new items, and preferring less healthy foods over healthy foods. Mothers most often cited perceived threats that pickiness could lead to unhealthy food preferences and adverse growth patterns (i.e., overweight, obesity, or underweight) for their infant in childhood and later in life. One mother explained, “everything scares me for her... I think that I have a bigger fear of her not liking food or eating well. That drives me to make sure she is eating healthy and eating a good variety of food” (P15-9 months). Several also cited concerns that pickiness would lead to the inconvenience of having to prepare separate meals for the infant than for the rest of the family. Across participants was a belief in a time-sensitive period during complementary feeding, in which specific strategies could influence an infant’s risk of, or protection from pickiness. To mitigate the perceived threat, many mothers introduced foods in strategic ways.

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These strategies comprised two subthemes: a) structuring the palate and, and b) modeling the ideal.

Structuring the Food Palate.

To avoid the perceived threat of their infant developing pickiness, most mothers used strategies to influence and guide the development of their infant’s palate, striving for their acceptance of a variety of healthy foods, flavors, and textures. One mother explained, “my sister’s two children were very picky eaters, and that's one of the reasons why I'm trying to introduce him to so many different things, because I do not want him to be a picky eater” (P2-11 months). Many mothers strategically exposed their infants to foods they perceived to be healthy during the complementary feeding period (e.g., fruits, vegetables, nutritious, colorful, whole, or real foods), with hopes they would continue to eat the foods as they grew older. One mother explained, “hopefully by starting with…vegetables and fruits, that’ll help encourage the vegetable and fruit eating as he grows up because he’s used to the flavors” (P1-9 months). To encourage food acceptance, mothers also reported offering previously refused food items multiple times. One mother explained, “I do know that the more you expose them to things they seem to not like, the better your chances of them actually liking them are. He's not … too picky with textures” (P18-16 months).

Mothers also frequently reported ways that they restricted foods to prevent narrowing dietary variety and the perceived threat of their infant developing pickiness. Many mothers limited exposure to unhealthy, but more palatable ingredients or foods (e.g., salt, sugar, fat, junk food, sweets, processed foods, fast-food, fried foods, and red meat). One mother expressed this as, “I think that what they eat now can really affect them later in life…I don't want to give her a bunch of sugar now and that be what she gets used to when she's older…be a picky eater and not

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want to eat her vegetables” (P21-11 months). Some mothers restricted their infant’s foods by the order they offered them to prevent narrowing of accepted foods. One mother explained, “At mealtimes I just introduce the food I want him to eat the most, first, because otherwise he'll eat the most attractive food to him first” (P18-16 months). To maintain a diet inclusive of healthy food items (i.e., a broad food palate), one mother restricted her infant to a single healthy item.

She said, “We get set in our ways and I know he'll eat certain things, so I'm just like, ‘Eat a ton of broccoli because it's healthy’” (P18-16 months).

Modeling the Ideal.

Mothers frequently reported using social modeling, in which they showed their infant how they themselves gardened, shopped, prepared, ate, and enjoyed healthy foods, as a strategy to prevent pickiness. One mother explained, I don't want her to be so picky…She eats everything that we're eating and sees what we're eating…starting young, then…as she grows up, she's not going to just like… her gummy snacks and pizza…” (P17-6 months). Many mothers encouraged their infant to self-feed as a strategy to reduce the perceived threat of pickiness. One mother explained, “we… would put it in front of her and let her feed herself…and…the benefits as far as how we started introducing foods, she's always very curious about what we want to eat. She's not a picky eater” (P16-12 months). Similarly, many mothers discussed specifically avoiding spoon feeding of traditional pureed foods to avoid the perceived threat of pickiness. One mother

explained, “when you give them food in jars, it feels like, you know, they eat it…, but they've never seen it, so when they actually see it, they're like, Oh, what is that?” (P19-12 months).

Several mothers reported avoiding social modeling of pickiness to their infants. One mother explained, “growing up, my mom didn’t like avocado, and so we didn’t eat it…and [I am] just

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making sure that whatever food stigmas that we have, I don’t say…I don’t like this, so you won’t like it either” (P14-12 months)

Discussion

Study findings expand our understanding of the perceived threats mothers experience when introducing new foods to their infant and how these perceived threats guide early life feeding decisions. Mothers in this study consistently reported perceived threats surrounding

complementary feeding, with the most common being perceived threat of choking, food allergies, and food pickiness. Results offer new insight into these perceived threats, how they may influence maternal decisions about introducing solid foods during the complementary feeding period, and common strategies mothers use during this period.

Mothers in this sample often inaccurately identified or overestimated risks, which likely heightened their perceived threats surrounding complementary feeding. For example, perceived threat of pickiness was identified by most mothers. Pickiness is a developmentally normal

presentation in infants and toddlers, typically resolving in early childhood.^91-93 However, mothers in this study, tended to perceived pickiness as a possible threat for adverse health and growth outcomes, consequences that are associated with longer lasting, atypical pickiness.^{94, 95} A lack of distinction between typical or mild pickiness and more severe forms may contribute to

inaccurately high levels of perceived threat, resulting in fear and confusion for mothers when they observe what may be developmentally normal pickiness.

There was a prevalence in misunderstandings about food allergies in this sample. Consistent with other studies, mothers often confused food intolerance (i.e., an undesirable digestive response to food), with food allergy (i.e., a systemic immune response to food).^96-98 With food

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intolerance, affected individuals can often consume small amounts of the food without

experiencing problems; however, for those with true food allergies, any exposure to the allergen may cause a severe and life-threatening event.⁹⁶ Misunderstandings about food allergies may impact a mother’s estimation of its prevalence.^{97, 98} While food allergies are relatively rare, mothers believed the more common, and less threatening food intolerances were true allergic reactions with the same corresponding health risks thus contributing to elevated perceived threats during the complementary feeding period.³⁴

Maternal responses to these heightened perceived threats often included strategies that were disproportionate to risks, at times, introducing additional and alternative risks. For example, many mothers reported delaying the progression of their infant’s diet from purees to more

advanced textures (i.e., chunky, lumpy, shredded, or chopped), and from spoon-feeding to self- feeding because of choking perceived threats. Yet, these strategies, may inadvertently place their infant at risk of developing pickiness.^{59, 76, 99} Complicating matters, many mother perceiving a threat of pickiness, used restrictive feeding practices, such as offering foods in a rigid order, completely avoiding some foods perceived to be unhealthy, and pressuring infants to eat foods they deemed healthy, strategies that may actually reinforce pickiness and/or poor growth patterns.88, 100-103

As with perceived threats of choking and pickiness, mothers’ heightened perceived threats about allergic reactions prompted them to approach complementary feeding with

excessive and at times inappropriate caution. For example, many mothers reported delaying the introduction of known highly allergenic foods, which may increase the risk of developing a food allergy.^{104, 105} Participants reported using intensive monitoring and preparation strategies like spacing of new foods, journaling of each food tried, CPR training, and purchasing of

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antihistamines to contend with their perceived threats about potential allergic reactions. These strategies seem excessive as not all food allergies are severe or life-threatening and the

prevalence of parent-reported food allergies is less than 8% in US children, with true prevalence likely lower due to overidentification.34, 98, 106 The intensive monitoring and preparation reported by mothers is not likely to help identify or mitigate the risks from an allergic reaction, because reactions rarely present with the first exposure, and mothers reported using these strategies only with the earliest introduction of new foods.^{34, 106}

Further making it difficult for mothers to make informed feeding decisions, professional recommendations for complementary feeding can appear inconsistent and sometimes contrary to one another and to the mothers’ own beliefs. For example, to ensure easy identification of an allergic reaction, the Centers for Disease Control and Prevention (CDC), Supplemental Nutrition Assistance Program for Women, Infants and Children (WIC), and American Academy of

Allergy, Asthma, and Immunology (AAAAI) recommend introducing new food items to infants gradually, and not more often than every 3-5 days.^78-80 Paradoxically, to reduce the likelihood of a child developing pickiness, the AAP advocates for early exposure to a wide variety of foods.⁷⁷ However, it would be difficult for parents to follow both recommendations, because spacing new foods to every 3-5 days would limit their ability to also provide a wide variety of foods during the brief window of complementary feeding.

Recommendations for preventing choking and pickiness can also appear contradictory to mothers. To reduce the risk of choking during the complementary feeding period, the CDC recommends feeding simple foods with limited textures, such as pureed foods and infant cereal.⁷⁹ Yet, the AAP, along with popular parent information sources across the US, encourages finger- feeding, in which infants self-feed finger foods that are soft and prepared in small pieces.72, 77, 107-

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109 However, there is limited empiric evidence to support one feeding method over the other.

Given the variations in recommendations, it is not surprising that mothers relied on their own perceived threats, often guided by inaccurate risk perception, for their decisions.

The new DGA guidelines for feeding infants 0 to 23 months old is a promising advancement in the world of complementary feeding.⁶¹ We now have clear and consistent guidelines for clinicians and policy makers to provide evidence-based education and support to families. Study findings of the maternal perceived threats and decision-making surrounding complementary feeding provide additional opportunities for more focused education as these guidelines gain momentum. Moving forward, healthcare providers should focus on presenting the DGA complementary feeding guidelines in a clear and consistent way, while also addressing common perceived threats. To help with the formation of healthy eating behaviors, it is critical for healthcare providers to educate mothers about developmentally appropriate pickiness and discourage the use of restrictive feeding methods. Similarly, frank discussions with families about the risks of an allergic reaction and what constitutes one, paired with encouragement to introduce allergenic foods early, may help to reduce the risk of developing food allergies.

Professional bodies that publish feeding recommendations should also work together to define risks and develop recommendations that keep infants safe from food allergies, while also promoting exposure to a wide variety of foods and textures during a sensitive period of taste development. Variability across recommendations makes young children even more vulnerable and at risk for developing unhealthy eating habits, as mothers rely on possibly inaccurate threat perceptions to guide their complementary feeding decision-making.

Findings highlight focal areas for future research. Specifically, future efforts should examine the relationships of maternal psychosocial factors, such as anxiety, depressive

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symptoms, and perceived threats, with complementary feeding practices. More examination of the level of safety of finger-feeding in infancy and its relation to pickiness, as well as the necessity of food spacing and its relation to food allergies is needed. Quantitative methods combined with qualitative strategies have the potential to further our understanding of these relationships and undergird development of future efficacious interventions and educational efforts tailored to reduce maternal perceived threats and manage perceived threats as well as reduce pickiness or food allergies, while ensuring infant safety.

Limitations

Our study adds to the growing body of knowledge surrounding complementary feeding practices by exploring the unique and personal perceived threats and strategies of mothers living in the central, eastern region of the US. Typical of qualitative research, this study included a small and geographically limited sample, and may not be generalizable to other groups of mothers and infants. Despite the limitation in regional generalizability, the in-depth interviews provided rich data from women with diverse backgrounds. Findings can help design future studies to further explore the relationships between maternal perceived threats and

complementary feeding transition strategies, as well as interventions to address perceived threats and knowledge gaps uncovered in this study.

The sampling strategy may limit some study findings. Most participants, especially those from middle- and upper-income backgrounds, self-selected and were therefore, more likely to be interested in the study topic. As a result, their responses and experiences may have been different from those who did not choose to participate. Nevertheless, the sample also included participants who were WIC clients, providing a unique perspective of mothers from low-income

backgrounds.

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33 Conclusion

The complementary feeding period is a brief but important phase, from which the

experiences may influence an infant’s health and growth across the lifespan. This study provides new insight into underlying perceived threats that may influence infant and toddler feeding decisions. Understanding these perceived threats and their corresponding impact on

complementary feeding strategies is critical to shaping

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34 CHAPTER 3

EXPANDING THE CONCEPT OF COMPLEMENTARY FEEDING: A STUDY OF MATERNAL PRACTICES, PRIORITIES, AND PERCEIVED THREATS

This chapter reports quantitative results of research question #1. This was a cross-

sectional, online survey that described several important CFP (i.e., texture intake, allergenic food exposure, spacing of new food introduction, and feeding method), as well as maternal

perceptions, such as perceived threats and priorities, related to complementary feeding. The results led to new insight regarding maternal perceived threats and priorities surrounding complementary feeding and expanded the definition of CFP. In this chapter, recommendations are made for clinical education surrounding complementary feeding, updated and consistent complementary feeding guidelines, and future research examining relationships of maternal factors with CFP.

Introduction

Early nutrition and food experiences are critical to an infant’s neurological and physical development.^{1, 2} A growing body of evidence suggests that early feeding practices influence eating preferences and subsequent dietary habits that may persist into adulthood, partially influencing growth and disease trends across the lifespan.^1-5 It is known that breastfeeding, timing and type of complementary food introduction, and certain parental feeding styles, such as authoritarian, permissive, or indulgent, are associated with growth and nutritional issues,

including childhood overweight and obesity. ^{2, 4, 6-11} Yet mothers, who are most often responsible for early infant feeding decisions, still struggle to know how and what to feed their infants.¹²

To facilitate healthier infant feeding practices, Dietary Guidelines for Americans (DGA), a longstanding nutrition and dietary reference in the United States (US), released its first

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guidelines for feeding infants in 2020.¹³ Most of the new DGA guidelines focus on

complementary feeding, an important dietary transition, in which an infant progresses from drinking only breastmilk or infant formula, to eating a variety of foods and textures. The new guidelines recommend introduction of allergenic foods around 6 months old and exposure to a variety of foods and textures. DGA refers readers to additional resources, such as those provided by the Supplemental Nutrition Assistance Program for Women, Infants and Children (WIC).

WIC recommends beginning complementary feeding with a parent-led, spoon-feeding method, and then allowing infant self-feeding from 6-8 months old.¹⁴

Despite this monumental effort to consolidate the evidence and update the guidelines, there are limitations in research related to some complementary feeding practices (CFP). A majority of CFP research focuses on the timing and type of complementary food introduction, but gaps exist in our understanding of other important CFP, such as allergenic food exposure, spacing of new food introduction, feeding method (i.e., spoon-feeding or infant self-feeding), and usual texture intake.^{4, 15-19}

A large body of complementary feeding research has explored responsive feeding, a reciprocal interaction in which a parent observes and modifies feeding behaviors i