Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Determinants of mothers’ solid food feeding practices during the transition period (4-9 months of age).. 2001

You don't seem to have a PDF reader installed, try download the pdf

Item Metadata

Download

Media
ubc_2001-0119.pdf
ubc_2001-0119.pdf [ 14.33MB ]
Metadata
JSON: 1.0089854.json
JSON-LD: 1.0089854+ld.json
RDF/XML (Pretty): 1.0089854.xml
RDF/JSON: 1.0089854+rdf.json
Turtle: 1.0089854+rdf-turtle.txt
N-Triples: 1.0089854+rdf-ntriples.txt
Citation
1.0089854.ris

Full Text

DETERMINANTS OF MOTHERS ' SOLID FOOD FEEDING PRACTICES DURING THE TRANSITION PERIOD ( 4 - 9 MONTHS OF AGE) : IMPLICATIONS FOR IRON NUTRITION By Loraina Stephen B S c , The University of British Columbia, 1994 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE D E G R E E OF MASTER OF SCIENCE In THE FACULTY OF GRADUATE STUDIES Department of Food, N u t r i t i o n and Hea l th (Human Nutrition) We accept this thesis as conforming to the required standard October 2000 THE UNIVERSITY OF BRITISH COLUMBIA © Loraina Stephen n2000 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of FLi iVuifTJ htiv\ The University of British Columbia Vancouver, Canada DE-6 (2/88) ABSTRACT ABSTRACT Sol id food feed ing is c o m p l e x and involves interact ion at m a n y leve ls . So l id food feed ing pract ices are de te rmined , in part, by the mother 's percept ions of infant food n e e d s , the infant's feed ing r esponses , and the mother 's knowledge a n d sk i l ls . It is known that by 9 months of age infants who are not bott le-fed with iron-fortified fo rmu la are at high risk for iron def ic iency a n e m i a and low iron s to res . D ie tary iron f rom comp lemen ta ry so l id foods is essent ia l to prevent iron def ic iency a n e m i a and iron deplet ion in t hese infants by 9 - 12 months of age . However , the content and bioavai labi l i ty of iron f rom sol id foods of fered dur ing the transit ion per iod is low. B e c a u s e of this, it is cr i t ical that infant feed ing prac t ices are appropr ia te to meet the infant 's evo lv ing nutrit ional requ i rements , espec ia l l y iron n e e d s , dur ing the transit ion per iod (4 to 9 months) . T h e s u c c e s s of infant feed ing requires that mothers learn both what and how to feed sol id foods . T h e present r esea rch u s e d a g rounded theory a p p r o a c h a n d in-depth interviews with 12 mothers to exp lore how mothers feed their infants a n d what in f luences the w a y they feed sol id foods dur ing the transi t ion per iod ( 4 - 9 months) . T h i s resea rch identif ied 5 t h e m e s that a re central to infant so l id food feed ing - the feeding process, perceiving infant food needs, ways of feeding, gaining expertise a n d tailoring the transition process. T h e central t heme that had the most inf luence on the so l id food feed ing p r o c e s s w a s how mothers were ' tai loring' the transit ion p r o c e s s . A 3 -d imens iona l concep tua l mode l of infant so l id food feed ing was deve loped to il lustrate the interact ion be tween the t hemes . A c a u s a l - c o n s e q u e n c e mode l w a s u s e d to bui ld a s e c o n d concep tua l m o d e l to link dietary iron a d e q u a c y to the p laus ib le re lat ionships that were identif ied f rom the 5 t h e m e s . F ind ings f rom this s tudy prov ide information n e e d e d for future deve lopmen t of effective multi- level educat ion s t ra teg ies that a re a i m e d at faci l i tat ing heal th p ro fess iona ls ' pract ices and mothers ' learning about the feed ing p r o c e s s a n d cond i t ions within the prox imate env i ronment that determine infant feed ing c h o i c e s a n d impact on the dietary intake of young infants. TABLE OF CONTENTS TABLE OF CONTENTS A B S T R A C T ii T A B L E O F C O N T E N T S iii LIST O F T A B L E S vi LIST O F F IGURES vi LIST O F A P P E N D I C E S vii A C K N O W L E D G E M E N T S viii 1. INTRODUCTION 1 1.1 Study purpose 3 1.2 Study objectives 3 2. L I T E R A T U R E REVIEW 4 2.1 Iron status - iron deficiency and anemia 5 2.2 Factors that influence infant iron status 7 2.2.1. Iron requirements and nutritional balance 7 2.2.2. Diet composition and food iron absorption 10 2.2.3. Dietary consumption patterns 13 2.2.4. Breast-feeding and weaning practices 18 2.3. Infant feeding guidelines 21 3. R E S E A R C H DESIGN A N D M E T H O D S 25 3.1 Introduction to qualitative research design 25 3.2 Design and methods 30 3.2.1. Ethics 31 3.2.2. Study participant inclusion criteria 31 3.2.3. Participant Recruitment 32 3.3 Data collection 32 3.3.1. Semi-structured Interview guide 33 3.3.2. Infant feeding Practices Questionnaire 34 3.3.3. Personal and Demographic Questionnaire 35 iii TABLE O F CONTENTS 3.4 Interview data management and analysis 35 3.4.1. Transcription from original data source 35 3.4.2. Data analysis 35 3.5. Questionnaire analysis 44 4. R E S U L T S 43 4.1 Participant characteristics 43 4.2 Overview 45 4.3 The feeding process 47 4.3.1. Starting the feeding process 48 4.3.2. Reasons for starting solid foods 50 4.3.3. Reasons for solid food selection 52 4.4. Perceiving infant food needs 56 4.4.1. Perceiving infant 'readiness' 57 4.4.2. Perceiving infant food 'preferences' 62 4.4.3. Perceiving infant 'hunger1 65 4.5. Ways of feeding 67 4.5.1. Offering and Waiting 70 4.5.2. Switching and Mixing 71 4.5.3. Adjusting feeding management 76 4.5.4. Socializing, Modeling, Engaging, and Playing 77 4.5.5. Positioning 78 4.5.6. Distracting, Sneaking/Camouflaging food 79 4.5.7. Prying, Stuffing or Forcing 80 4.5.8. Pushing 81 4.5.9. Holding back food 84 4.5.10. Solid food feeding strategies summary .88 4.6. Gaining expertise 90 4.6.1. Finding and using resources 92 4.6.2. Being a first time mother and feeling scared 94 4.6.3. Seeking reassurance ....95 4.6.4. Learning through trial and error.. 98 4.7. Tailoring the transition process 101 4.7.1. The causal-consequence model 101 4.7.2. Dietary intake patterns 108 4.8 Questionnaire 115 iv TABLE OF CONTENTS 5. DISCUSSION 123 5.1 Determinants of so l id food feeding pract ices 123 5.2 T h e conceptua l mode ls of infant sol id food feeding 132 5.3 T h e c a u s a l - c o n s e q u e n c e mode l of infant sol id food feeding 133 5.4 Study limitations 137 5.5 Conc lus ions 141 6. F U T U R E DIRECTIONS 144 6.1 . R e s e a r c h 144 6.2. Pract ice 145 R E F E R E N C E S 146 APPENDICES 154 V TABLE OF C O N T E N T S LIST O F T A B L E S Tab le 1. Descr ipt ion of the participant character ist ics 44 Tab le 2. S u m m a r y of sol id food feeding strategies 88 Tab le 3 . T h e resources u s e d by study part icipants 92 Tab le 4. T h e range of sol id foods fed to infants between 3 - 9 months of age 109 LIST O F F IGURES Figure 1. C h a n g e s in body iron content dur ing in fancy 8 F igure 2. T h e effects of dietary compos i t ion o n the relative bioavai labi l i ty of iron 13 F igure 3. T h e C o n c e p t - Indicator M o d e l 27 F igure 4. T h e C a u s a l - C o n s e q u e n c e M o d e l 2 8 F igure 5. Transcr ip t o rgan izat ion a n d line cod ing (LC) p rocedures 36 F igure 6. Indicator Index S u m m a r y S p r e a d s h e e t (MSS) for l ine c o d e organ izat ion 38 F igure 7. M e m o S p r e a d s h e e t ( M S a ) 3 9 F igure 8. C o n c e p t / C a t e g o r y S u m m a r y S p r e a d s h e e t ( C C S S ) 40 F igure 9. M e m o S p r e a d s h e e t ( M S b ) 41 F igure 10. T h e 3 - d imens iona l infant so l id food feed ing mode l 46 F igure 11 . T h e first t heme of the 3 - d imens iona l infant so l id food feed ing mode l 47 F igure 12. T h e s e c o n d t heme of the 3 - d imens iona l infant so l id food feed ing mode l 57 F igure 13. T h e third t h e m e of the 3 - d imens iona l infant so l id food feed ing mode l 69 F igure 14. T h e fourth t heme of the 3 - d imens iona l infant so l id food feed ing mode l 91 F igure 15 . T h e c a u s a l - c o n s e q u e n c e m o d e l of infant so l id food feed ing 103 F igure 16. T h e type of milk fed from birth to12 infants 114 F igure 17. T h e iron-fortified infant ce rea l consump t i on patterns a m o n g infants 135 vi TABLE OF CONTENTS LIST O F A P P E N D I C E S A P P E N D I X A : Baby ' s First F o o d s B . C . Ministry of Heal th 154 A P P E N D I X B: Eth ics Approva l 155 A P P E N D I X C : Letter of Informed C o n s e n t 156 A P P E N D I X D: Recrui tment Check l is t 157 A P P E N D I X E: Infant Feed ing Prac t ices Quest ionnai re 158 A P P E N D I X F: Demograph ic Quest ionnai re 169 A P P E N D I X G : Transi t ion G r a p h s 176 A P P E N D I X H: Feed ing Techn iques 183 A P P E N D I X I: Feed ing Strategies S u m m a r y 184 vii ACKNOWLEDGEMENTS ACKNOWLEDGEMENTS I apprec iate and s incere ly thank my superv isor Dr. She i la Innis for giving m e the opportunity to do this unique research project. Her firm gu idance and support over the past years has m a d e m e strive hard to do m y best. M a n y thanks to my other commit tee members Dr. G w e n C h a p m a n and Dr. Phyl l is J o h n s o n for their excel lent ass is tance , gu idance and support in this chal lenging project. I a lso wish to thank m y examin ing commit tee members He len Y e u n g and Dr. R y n a Levy-Mi lne for taking the t ime to review m y thesis project and for their insight and expert ise. I wou ld l ike to thank the mothers who part ic ipated in this s tudy s o that I cou ld learn f rom them and hopefu l ly a d v a n c e unders tand ing in the a r e a of infant so l id food feed ing and nutrit ion. I wou ld l ike to ex tend a very big thank you to m y f r iends for their unfai l ing suppor t dur ing the more difficult s t re tches a n d lots of fun and laughter dur ing the best t imes. T h a n k you V ikk i , Sy l v i a , Patty, C a r o l a n n e , A n g e l a a n d S a n d r a . A very s p e c i a l thank you to m y wonder fu l fami ly; D o n , Ian, P e d r a , Hubert , and J o a n who had to m o v e f rom their h o m e and fami ly to a c c o m m o d a t e m y s tud ies. The i r love and smi l ing f aces never c e a s e d to be a sou rce of inspirat ion. M a n y thanks to my mother and her h u s b a n d D o n , who have a l w a y s be l ieved I cou ld do anyth ing a n d to my mother- in- law S a n d y who has a lways been there ove r the yea rs w h e n I n e e d her. T o m y brother, who cont inues to remind m e that h igher educa t ion is highly over ra ted. Last ly , m y deepes t grati tude and love to m y h u s b a n d , who has a lways e n c o u r a g e d m e in m y educat ion and intel lectual adventures . viii INTRODUCTION Chapter I T h e transi t ion per iod in infant feed ing is def ined a s the t ime w h e n semi -so l id foods are in t roduced to infants, usua l l y at about 4 - 6 mon ths of a g e . W i t h a c c e p t a n c e in inc reas ing quant i t ies, so l id f oods s lowly rep lace the exc lus i ve milk diet a n d the diet p rog resses to a 'modi f ied ' table diet. T h e transit ion to a 'modi f ied ' table diet is usua l l y comp le te by 1 - 2 yea rs of age . Infant feed ing dur ing the ear ly transit ion per iod occur r ing f rom 4 - 9 months is c o m p l e x b e c a u s e of severa l key i s s u e s - in tense growth and thus high nutrient requ i rements , the deve lopmen ta l s t age and thus phys ica l read iness of the infant to accep t foods , and interact ions be tween the mother - the infant - and the env i ronment . Infancy is a t ime of great nutritional vulnerabi l i ty b e c a u s e it is a per iod of in tense growth and l imited dietary variety. For ins tance , a n 8-month-o ld infant requ i res more than three t imes a s m u c h iron per k i logram body weight than the ave rage adult ma le , a n d over two-thirds of this iron is n e e d e d for growth (Da l lman, 1992). G radua l l y expand ing the exc lus i ve milk diet (breast milk or formula) to inc lude sol id foods e n a b l e s young infants to meet their c h a n g i n g nutrit ional n e e d s . W e a n i n g recommenda t i ons are b a s e d on three major factors: nutrit ional n e e d , phys io log ica l matura t ion 1 a n d d e v e l o p m e n t a l 2 feed ing i s s u e s (Hendr icks and Badrudd in , 1992). B a s e d on these factors, it is usua l l y r e c o m m e n d e d that the introduction of so l id foods beg ins be tween 4 and 6 months of age . T h e r e c o m m e n d a t i o n s are c o n s i d e r e d ' idea l ' b e c a u s e a s the milk diet b e c o m e s nutritionally insufficient (Wh i thead , 1985a ,b ; W H O , 1985 ; U n d e r w o o d 1985 ; F o r m a n , 1984) the addi t ion of comp lemen ta ry foods c o m p e n s a t e s for the nutrients that b e c o m e l imited, thus providing a nutrit ionally adequa te diet. T h e major nutrients of c o n c e r n dur ing in fancy in industr ia l ized countr ies inc lude energy , iron, and v i tamin D. Iron def ic iency, in part icular, is a nutrit ional prob lem a m o n g infants and young chi ldren in C a n a d a . T h u s , prevent ion of iron de f i c iency a n e m i a is a pr imary focus of nutrition expert g roups ( C P S , 1 9 9 1 ; C P S , 1998; Heal th a n d We l f a re C a n a d a , 1986; T h e V a n c o u v e r Heal th Depar tment , 1993) in C a n a d a . 1 Physiological maturation includes renal function capacity (increased concentrating and excretory capacity) and gastrointestinal function (increased gastric capacity, bile acid pool, pancreatic amylase, pepsin and matured microvillus membrane structure). 2 Developmental feeding issues include the extrusion reflex, the head, trunk, gross and fine motor control and exploratory behavior. 1 INTRODUCTION T h e a g e of onset of wean ing is important b e c a u s e it is known that introducing sol id foods ' too early 5 or ' too late' c a n h a v e negat ive heal th c o n s e q u e n c e s (Hendr icks a n d Badrudd in , 1992). B y 4 - 6 months of a g e the intestine and k idney ( G r a n d , 1976 ; S c a m m o n , 1990; A k r e , 1989) are better d e v e l o p e d to d igest a n d a b s o r b c o m p l e x foods , a n d the infant is reach ing important phys i ca l a n d neuro log ica l mi les tones ( Ingram, 1962; G e s e l l , 1937 ; P r i d h a m , 1990) n e e d e d for s u c c e s s f u l so l id food intake. A n infant fed so l i ds ' too e a r l y is at i n c r e a s e d r isk for d ia r rhea a n d al lergic d i s e a s e d u e to intestinal immaturity, wh i ch m a y c a u s e malnutr i t ion. In addi t ion, ear ly so l id food introduction m a y lead to d e c r e a s e d breast-mi lk product ion b e c a u s e so l id foods c a n d i sp lace milk intake. Infants fed so l ids ' too late', on the other hand , m a y d isp lay negat ive o u t c o m e s , including iron de f i c iency a n e m i a b e c a u s e human milk a lone canno t meet iron n e e d s in the s e c o n d s ix months of life. C o m p l e m e n t a r y sol id foods that are a g e a n d nutrient appropr ia te a re , therefore, essent ia l for normal infant growth and deve lopment . Iron de f i c iency a n e m i a 3 (IDA) is the mos t c o m m o n nutritional de f i c iency in the wor ld, affect ing about a quarter of all infants wor ldwide (Lozoff , 1996) . IDA is most prevalent be tween 6 and 24 months of a g e b e c a u s e the iron s tores accumu la ted dur ing gestat ion are dep le ted by this t ime and the requi rements to meet growth n e e d s a re h igh. Further, the iron content and absorpt ion of different so l id foods c o m m o n l y fed to infants dur ing the t ransi t ion per iod var ies . T h e compos i t ion of var ious food combina t ions c a n a l s o posi t ively or negat ive ly in f luence iron bioavai labi l i ty (e.g. , e n h a n c e or inhibit iron absorpt ion) . F o r s o m e infants, ear ly feed ing of non-fortif ied cows ' milk that is low in iron further i nc reases the risk of iron de f i c i ency 4 ( C P S , 1991). A l though the nat ional p reva lence of iron def ic iency in in fancy in C a n a d a is unknown s o m e populat ions of infants are at high risk for poor iron s tatus. A recent study in V a n c o u v e r found about 1 5 % of breast - fed 9-month-o ld infants had iron def ic iency a n e m i a , and a further 3 0 % were iron def ic ient (Innis et a l . , 1997) . A l though the types of so l id foods a n d h o w foods are fed to infants dur ing the transit ion per iod c a n inf luence dietary iron a d e q u a c y , da ta a re lack ing on the sol id food feed ing p r o c e s s . Hea l th ca re p ro fess iona ls , (Nutri t ionists, Pub l i c Hea l th N u r s e s a n d Doctors) and mothers t h e m s e l v e s interpret a n d use the current infant feed ing recommenda t i ons . 3 Iron deficiency anemia is defined as the final stage of iron deficiency where there is decreased hemoglobin synthesis and clinical abnormalities (erythrocytes are microcytic and hypochromic). Anemia occurs when iron deficiency is severe. 4 Iron deficiency is a process of gradual depletion of iron content in the body. The first stages of iron deficiency coincide with the depletion of iron stores, the second stage with inadequate iron transport to the bone marrow. 2 INTRODUCTION However, data are lacking on how mothers feed iron containing solid foods, how mothers interpret the guidelines (CPS, 1998) or whether or not mothers can follow the recommendations put forth by the guidelines, in a natural setting. The following research was undertaken to contribute to the gaps in the literature on determinants of mothers' solid food feeding practices during the transition period. 1.1. Study purpose The purpose of the present research was exploratory, to learn about how mothers feed solid foods to their infants, what influences their feeding practices in a natural setting and how these feeding practices impact on iron nutrition. Very little information has been published on complementary solid food feeding practices during the transition period. A clear understanding of how mothers feed infants solid foods is required in order to understand how to modify the infant's diet to prevent iron deficiency anemia. A qualitative research approach was used to describe the solid food feeding process and identify factors that determine mothers' solid food feeding practices. Qualitative research methods were chosen because these methods are best suited for exploratory research where basic knowledge building is a primary focus. 1.2. Study objectives The objectives of this study were: 1. To identify mothers' solid food feeding practices, focusing specifically on iron-fortified infant cereals, (e.g., what cereals are fed, the preparation methods and the patterns of cereal intake over time) during the transition period when infants are between 4 to 9 months of age. 2. To identify why mothers feed their infants solid foods in the way that they do, focusing on what influences cereal feeding practices and decisions. 3. To explore the link between the mothers' solid food feeding practices and current solid food feeding recommendations forth by expert groups for the transition to solid foods and the prevention of iron deficiency anemia (Canadian Pediatric Society, Dietitians of Canada and Health Canada in Nutrition for Healthy Term Infants, 1998). 3 LITERATURE REVIEW Chapter II Infancy is an important per iod for phys ica l a n d cogni t ive deve lopment b e c a u s e at this t ime nutrit ional p rob lems c a n have long-term effects both on at ta inment of phys ica l growth and on cogni t ive funct ions. T h e nutrit ional a d e q u a c y of the infant diet and factors that inf luence food intake are crit ical for heal th and ach ievemen t . T h e diet p lays an important role in infant iron status b e c a u s e up to 3 0 % of the infant 's body requi rement for iron must be der ived f rom dietary s o u r c e s (Smi th, 1974; F o m o n , 1974) . Iron de f i c iency a n e m i a (IDA) is most prevalent be tween 6 - 2 4 months of a g e . Th i s is further e m p h a s i z e d by the fact that IDA is the most c o m m o n s ingle nutrient de f i c iency in the wor ld , affect ing approx imate ly 2 0 - 2 5 % of infants wor ldwide (Lozoff 1996). R e s e a r c h is lack ing o n the nat ional p reva lence of iron def ic iency a m o n g infants in C a n a d a . Howeve r , the s tud ies that have b e e n comp le ted have found that iron def ic iency a n e m i a is a cons ide rab le p rob lem, affect ing 7 to ove r 5 0 % of young infants ( C h a n Y i p and G r a y - M a c D o n a l d , 1987; G u p t a , et a l . , 1999 ; Innis et a l . , 1997; L e h m a n n et 'a l . , 1992 ; S a w c h u c k et a l . ,1996; W a l e n et a l . , 1997; W i l l ows et a l . , 2000) . Dur ing the transit ion per iod be tween 4 a n d 9 months of a g e , milk is gradual ly rep laced with semi -so l id food . T h e high risk of iron de f i c iency in the s e c o n d s ix months of life co inc ides with the transit ion per iod. Both factors - the high d e m a n d for iron d u e to in tense growth a n d the low iron content a n d bioavai labi l i ty of so l id f oods in the t ransi t ion diet (Fai rweather-Tai t et a l . , 1989 ; L y n c h , 1997) i nc rease the risk of iron def ic iency. R e s e a r c h on iron a n d so l id food feed ing h a s f o c u s e d primari ly o n the a g e at w h i c h comp lemen ta r y (sol id) f oods are in t roduced to infants with little invest igat ion on unders tand ing the more comp lex behav iora l factors that de termine sol id f ood feed ing over t ime, and thus potent ial ly in f luence infant iron nutrit ion. C lear l y , the w a y a mo the r 5 f eeds her infant iron conta in ing sol id foods has the potential to impact on the infant's a c c e p t a n c e of the foods , a n d thus food consumpt ion patterns a n d dietary iron a d e q u a c y . 5 The primary person usually feeding an infant is the mother. However, other people besides the mother also feed infants. For the purpose of this study that involves interviewing mothers, the word "mother" refers to the primary feeder/caregiver. 4 LITERATURE REVIEW Information o n what mot ivates mothers to feed their infants so l id foods the w a y that they do is a lso lack ing. M u c h of the resea rch o n factors inf luencing infant feeding c h o i c e s has f o c u s e d on the determinants of b reast - feed ing initiation and durat ion. A l though this is interrelated with the introduction of so l id foods , de terminants of b reast - feed ing c h o i c e s cannot be ext rapolated to unders tand ing the so l id food feed ing p r o c e s s dur ing the transit ion per iod. T h e ef fec t iveness of infant feed ing r ecommenda t i ons d e s i g n e d to d e c r e a s e the r isk of iron def ic iency a n e m i a shou ld be b a s e d , fundamenta l ly , on their ef f icacy, c o m p r e h e n s i v e n e s s and pract ical utility within the natural set t ing, a s wel l a s the d ietary iron content . Th i s review prov ides an overv iew of current r esea rch in key a reas relevant to infant iron nutrition be tween the a g e of 4 and 9 months w h e n mos t heal thy infants are undergo ing the gradua l transit ion f rom an exc lus i ve milk diet to a diet with milk and semi -so l id comp lemen ta ry foods . T h e ma in a r e a s this rev iew will f ocus o n are iron status, iron requi rements and nutrit ional ba l ance , diet compos i t i on a n d food iron absorp t ion , d ietary consumpt ion patterns, food a c c e p t a n c e , breast - feed ing a n d wean ing prac t ices , a n d the infant feed ing gu ide l ines . B reas t - feed ing prac t ices a re d i s c u s s e d b e c a u s e they are c l ose l y interrelated to the sol id food diet and the risk of iron de f i c iency a n e m i a . Cur rent infant feed ing gu ide l ines are a lso desc r i bed to prov ide an unders tand ing of the informat ion that is ava i lab le for heal th pro fess iona ls and the publ ic about the transit ion to so l id foods a n d prevent ion of iron de f i c iency a n e m i a during infancy. 2.1. Iron status - iron deficiency and anemia T h e impor tance of ensur ing adequa te dietary iron in takes in infants and ch i ldren a s a b a s i s tor prevent ion of i ron de f i c iency is a pub l ic hea l th priority b e c a u s e i ron-def ic iency m a y b e assoc ia ted with detr imenta l ef fects on the infant 's behav io ra l , cogni t ive and motor deve lopmen t ( F o m o n and Zlotk in , 1992) . T h e r e is a l so ev i dence that the treatment of iron de f i c iency a n e m i a m a y not comple te ly correct the a d v e r s e ef fects on cogni t ive deve lopment (Idjradinata et a l . , 1993 ; Lozof f et a l . , 1991 ; Lozof f et a l . , 1996 ; Pollitt et a l . , 1993 ; Wa l te r et a l . , 1989). In addi t ion, an ima l s tud ies have s h o w n that iron de f i c iency al ters neuro log ica l funct ion and that the effects a re 5 LITERATURE REVIEW related to an insuff icient supp ly of iron to different t i ssues for the syn thes is of var ious iron c o m p o u n d s , s u c h a s e n z y m e s (Bynes , 1994; B e a r d et a l . , 1993). Current da ta on the p reva lence of iron de f i c iency a n d iron def ic iency a n e m i a (IDA) in C a n a d i a n infants a re l imited. T h e p reva lence of IDA a m o n g 6 - 1 4 month old infants l iving in a low s o c i o - e c o n o m i c env i ronment w a s reported to be 25 - 2 7 % (Lehman et a l . , 1992; C h a n - Y i p and G r a y - D o n a l d , 1987) . H igh p reva lence rates of IDA have been reported in First Nat ion infants in C a n a d a (Moffatt, 1995 ; S a w c h u c k et a l . , 1996 ; W i l l ows et a l . , 2 0 0 0 ; W a l e n et a l . , 1997). A recent s tudy in B e l l a Be l l a , Br i t ish C o l u m b i a found that 5 2 % of infants be tween the a g e s of 6 and 24 months had a n e m i a (Hgb <100g/L) ( S a w c h u k et a l . , 1996) . In northwestern Ontar io , 71 - 7 9 % of 6 to 12 month o ld infants had IDA (Hgb <110g/L) (Wa len et a l . , 1997). In northern Q u e b e c , 3 1 % of the infants had IDA (Hgb <110g/L) at 9 months of a g e (Wi l lows et a l . , 2000) . Infants from 8 to 18 months of a g e in h igher s o c i o - e c o n o m i c env i ronments and urban centers a p p e a r to have much lower p reva lence rates, ranging f rom 3.5 % to 7 % (Greene -F ines tone et a l . , 1989; Innis et a l . , 1997; Z lotk in et a l . , 1996). A l though breas t - feed ing offers s o m e protect ion aga ins t the deve lopment of IDA ( C P S 1998; McMi l l i an et a l . , 1976 ; P i z z a r o et a l . , 1991), other s tud ies have found that a longer durat ion of breast - feeding is a s s o c i a t e d with i nc reased risk (Ca lvo et a l , 1992 ; C h a n - Y i p and G r a y - D o n a l d , 1987; Hertrampf et a l . , 1986 ; Innis et a l . , 1997; K i m et a l . , 1996; S i i m e s et a l . , 1984; Wi l l ows et a l . , 2000) . F i ve recent s tud ies have indicated major d i f ferences in IDA be tween breast and formula- fed infants at about 9 months of age . A l though a recent s tudy in V a n c o u v e r found the overal l p reva lence of IDA w a s 6 .7%, infants who we re breast - fed for longer than 8 months had a p reva lence of 1 5 . 5 % (Innis et a l . , 1997). W i l l ows et a l . , (2000) found that IDA is highly prevalent a m o n g First Nat ion infants. T h e s e authors reported s t rong assoc ia t i ons be tween hemog lob in concentrat ion a n d the type of milk feed ing at 9 months of a g e . T h e y reported 4 3 % of breast- fed and 1 6 % of formula- fed infants had IDA (Hgb <110g/L) at 9 months of age . S e v e r e a n e m i a (Hgb <100g/L) was found a m o n g 1.3% of the infants fed fo rmu la and 1 7 % of the infants who were breast- fed (Wi l lows et a l . , 2000) . P izar ro et a l . , (1991) c o m b i n e d the results of three s tud ies involving a total of 854 9 month old infants comp le ted be tween 1975 and 1985 , in San t i ago , 6 LITERATURE REVIEW Chile and reported a prevalence of IDA of 14.7% (Hgb <110 g/L) among infants fed human milk, 20.2% among infants fed cows' milk, and 0.6% among infants fed iron-fortified formula. Walter et al., (1993) found that feeding iron-fortified cereal to breast-fed infants decreased the percentage of infants with a low hemoglobin (<105g/L) by more than half to 12% from 27% by 15 months of age. This trend was evident by 8 months of age in that about 10% of the infants fed fortified cereal and about 15% of infants not fed fortified cereal had low hemoglobin levels (<105g/L). Of note, the prevalence of IDA in this study for breast-fed infants in Chile who were not fed iron- fortified cereal is very similar to that reported for breast-fed infants in Vancouver by Innis et al., (1997). Calvo et al., (1992) found that 27.8% of 9 month old breast-fed infants in Argentina had IDA (Hgb <100g/L) compared with 7.1% of infants fed formula. In summary, breast-feeding does not appear to completely protect the infant from iron deficiency in the second six months of life, and feeding with iron-fortified infant cereal decreases the risk of IDA at 8 - 9 months of age. 2.2. Factors that influence infant iron status. 2.2.1. Iron requirements and nutritional balance. The requirement for dietary iron per kilogram body weight is greater during infancy and childhood than at any other period in life (Dallman, 1980; Oski, 1989). There is very little change in the total body iron content of the healthy term infant between birth and 4 months of age (Oski, 1989). Abundant iron stores are laid down in the developing fetus in the last months of pregnancy and in the infant shortly after birth from the breakdown of fetal haemoglobin (Hallberg, 1992). Through these processes the iron stores of the healthy term infant provides a phase of iron self-sufficiency that makes it unlikely that the infant will become iron-deficient before about 6 months of age (Dallman, 1992; L R S O , 1998; Simmes 1984; Stekel, 1984). From 4 - 12 months of age, the total body iron content almost doubles (Dallman, 1986). The rapid growth during the second six months of life, and the accompanying rapid expansion of blood volume quickly depletes the infant's iron reserves. After 6 months of age the risk of iron deficiency is high and the adequacy of the dietary iron supply becomes critical. For example, in the 1-year old infant approximately 30% of the body's iron needs for growth and blood volume expansion must be 7 LITERATURE REVIEW provided by the diet (Smith, 1974; Fomon, 1974). The iron of human milk, unfortified infant formula and cows' milk is inadequate to meet the infant's iron requirements, thus other dietary sources are needed from 4 - 6 months of age when the infant's iron stores are no longer able to prevent iron deficiency (Dallman, 1980). Figure 1 illustrates the changes in body iron during the first year of life. Total boctyiraXiTg) H9crage • Ivyô cbin+Enzymes | • hferTDfJcb'n Figure 1. Changes in body iron content during infancy. The requirement for dietary iron is minimal until about 4 months of age because storage iron is used of to support the needs for hemoglobin and iron-containing enzymes. In contrast, a large quantity of iron must be assimilated during the remainder of infancy, and are needed from the diet to support the rapid increase total body iron (adapted from Dallman, P.R., 1986) Iron requirements during the second 6 months of life are based on estimated obligatory iron losses, which include intestinal, skin and urine losses averaging 0.37 mg per day (0.04 mg/kg). Iron accretion for growth and iron stores is estimated at 0.34 mg/day. Thus, the total iron requirement is set at 0.7 mg/day and the dietary iron intake recommended to meet this requirement, assuming an absorption of 10%, is 7.0 mg/ day from 5 - 1 2 months of age (Health and Welfare Canada, 1990). Iron balance is a physiological state in which the quantity of iron absorbed from the diet is sufficient to offset daily iron losses, to allow iron utilization for physiological functions, and to 8 LITERATURE REVIEW maintain adequa te iron s to res . Iron de f i c iency p r o g r e s s e s in three s tages or deg rees of sever i ty. T h e first s tage co i nc i des with the dep le t ion of i ron s to res . T h e s e c o n d s tage co inc ides with the i nadequacy of iron transport to the bone marrow. T h e third and most seve re s tage, a n e m i a , co inc ides with a defect in haemog lob in product ion (Hercberg a n d G a l a n , 1992). T h e impai rment in the product ion of essen t ia l iron c o m p o u n d s is referred to a s iron def ic iency. W h e n essent ia l iron c o m p o u n d s s u c h a s haemog lob in , mi tochondr ia l i ron prote ins (cy tochromes) a n d iron sul fur proteins, that funct ion in ox idat ive product ion of cel lu lar energy in the form of adenos ine t r iphosphate a re l imited then impa i red phys io log ica l funct ion is l ikely (Fi ler, 1989). L o w iron s tores per s e indicate that the infant is vu lnerab le to iron def ic iency; the lower the s tores the more vu lnerab le the infant b e c o m e s (Da l lman, 1989) . T h e te rm iron de f i c iency d o e s not prov ide a spec i f ic descr ip t ion of the d e g r e e of iron dep le t ion. Iron de f i c iency a n e m i a (IDA), on the other hand , is a hemato log ic state that resul ts f rom iron def ic iency. In IDA, the body iron s to res (ferritin and hemosider in ) h a v e b e e n exhaus ted and the infant is in the last s tage of iron def ic iency in wh i ch there is insuff icient i ron for the syn thes i s of hemog lob in . T h u s , IDA is the e n d result of a cumula t ive p r o c e s s of iron dep le t ion that occu rs over a per iod of months . T h e measu remen t of both s e r u m ferritin a n d haemog lob in reflect the iron s ta tus of a lmos t 9 0 % of body iron (Bothwel l , 1979). T h e 4 key factors that in f luence infant iron status a n d risk of iron def ic iency are the a b u n d a n c e of neonata l iron s to res , b o d y iron l o s s e s (basa l , patho log ic , gastro- intest inal b leeding) , the high d e m a n d s for iron dur ing rapid growth a n d the iron content of the diet. T h e iron content of the diet d e p e n d s o n the quant i ty c o n s u m e d , the fo rm of iron (heme or n o n - h e m e iron), and the overa l l diet compos i t i on (Bothwel l et a l , 1989 ; Char l ton and Bothwel l , 1983 ; C o o k and Bothwel l , 1984 ; Ha l l be rg , 1 9 8 1 ; M c M i l l i a n et a l . , 1976 ; S a a r i n e n et a l . , 1977). O f t hese 4 factors , the infant's diet is the most highly modi f iab le . There fo re , the bas is of prevent ion of IDA dur ing in fancy is d ietary modi f icat ion. A c lea r unders tand ing of how mothers f eed infants so l id f oods is required in o rder to unders tand how to modi fy the infant 's diet to prevent iron def ic iency. 9 LITERATURE REVIEW 2.2.2. Diet composition and food iron absorption T h e diet c a n inf luence infant iron s ta tus and the risk of IDA in 3 w a y s : the iron content (quantity), the form of iron ingested (heme or n o n - h e m e iron) and the compos i t ion of the diet (Bothwel l et a l . , 1989; Char l ton and Bothwe l l , 1983 ; C o o k and Bothwel l , 1984; Ha l lberg , 1981 ; McMi l l i an et a l . , 1976; S a a r i n e n et a l . , 1977) . T h e major s o u r c e s of dietary iron in later infancy are breast milk, iron-fortified infant fo rmu las , iron-fortif ied infant ce rea ls and mea ts . H u m a n milk prov ides about 0.26 m g of iron per day , b a s e d on a typical dai ly consumpt ion of 7 5 0 m L mi lk /day with an iron content of 0 .35 m g / L milk (Saar inen , S i i m e s et a l . , 1977; Hea l th and W e l f a r e C a n a d a , 1990) . H o w e v e r , the range of iron in h u m a n mi lk var ies be tween 0.2 to 0.8 mg /L ( L R S O , 1998). Further, the absorp t ion of iron f rom human milk ranges f rom 12 to 5 0 % (Abrams et a l . , 1997 ; D a v i d s s o n et a l . , 1994b ; Ha l lberg et a l . , 1992 : M c M i l l a n et a l . , 1977; S a a r i n e n et a l . , 1977: S c h u l z - L e l l et a l . , 1987) . At an ave rage iron content of 0.26 m g , and a s s u m i n g 5 0 % absorp t ion , the infant wou ld abso rb about 0.12 mg /day of iron f rom human milk. Al ternately, a s s u m i n g the m a x i m u m iron in h u m a n milk of 0.8 mg/L , a m a x i m u m absorpt ion of 5 0 % , a n d a high consumpt ion level of 1000 m L of milk per day , the infant wou ld abso rb a theoret ica l m a x i m u m of about 0 .40 m g i ron/day. Howeve r , with m a x i m u m absorpt ion and the m in imum iron content in h u m a n milk (0.2 mg/L ) , the infant wou ld abso rb on ly about 0.10 m g iron per day . Simi lar ly , s i nce iron absorp t ion d e c r e a s e s with the inc reas ing amount of iron prov ided f rom the food , a s s u m i n g a more l ikely absorp t ion rate of 1 2 % with 0.8 mg /L iron, the infant wou ld a l s o on ly a b s o r b about 0 .10 m g i ron/day f rom 1000 m L of milk. T h i s 4-fold d i f ference in potent ia l iron absorpt ion a m o n g the breast - fed infants c rea tes cha l l enges to est imat ing the amount of iron obta ined f rom breast milk a lone , a n d thus f rom comp lemen ta ry foods . Infant ce rea l con ta ins approx imate ly 3 m g of iron (2.7 - 3.5 mg) per 3 tab lespoons of dry infant ce rea l (Heal th and We l f a re C a n a d a , 1986) . R i o s et a l . , (1975) found that the m e a n absorpt ion of electrolyt ic iron f rom m ixed ce rea l w a s 4 . 0 % . Wi th an absorpt ion of 4 .0%, 4 tab lespoons of dry infant ce rea l wou ld prov ide about 0 .13 m g of iron. T h e comb ined total iron content of h u m a n milk (0 .3mg/L) p lus 8 t a b l e s p o o n s of infant ce rea l per day cou ld theoret ical ly prov ide about 0.6 m g , c l o s e to the es t imated requi rement of 0.7 mg/day . C lear ly , the sol id food 10 LITERATURE REVIEW feed ing p rac t i ces of the mother will affect the so l id food intake, a n d thus iron status of the infant. T h u s , an unders tand ing of factors that in f luence infant so l id food consumpt ion patterns is important to identifying pract ices that p romote or d e c r e a s e the consumpt ion of iron-fortified first foods . In addi t ion to the quanti ty of iron in food , both the form of the iron and the compos i t ion of .the diet a lso in f luence iron bioavai labi l i ty. In fact , the fo rm of the iron in food a n d the effect of food combina t ions on iron bioavai labi l i ty c a n have a greater impact on iron nutrition than the total amoun t of iron in the diet (Char l ton et a l . , 1983 ; C o o k e t a l . , 1984; Ha l lberg , 1981 ; McM i l l an et a l . , 1976; O s k i et a l . , 1980 ; S a a r i n e n et a l . , 1977) . T h e interplay be tween promoters and inhibitors of iron absorp t ion are key to the bioavai labi l i ty of n o n - h e m e iron. A brief review of the types of iron in the diet is n e e d e d in order to unders tand iron absorpt ion and il lustrate the potent ial d i f ferences in iron absorp t ion in relation to the type of comp lex mea l s an infant might c o n s u m e . T h e two fo rms of iron in the diet - h e m e a n d n o n - h e m e iron, differ with respect to bioavai labi l i ty (Hal lberg, 1989; R o s s a n d e r - H u l t h e n and Ha l lberg , 1996). H e m e iron wh ich is present in an ima l t i ssues is a b s o r b e d at a high rate ( -25%) and this absorpt ion is genera l ly independent of iron status and dietary inhibitors and promoters of iron absorpt ion ( M o n s e n et a l . , 1978). N o n - h e m e iron, wh ich is found in non meat s o u r c e s including dairy foods , has a w ide range of absorp t ion of 5 - 2 0 % , a n d the absorp t ion of n o n - h e m e iron d e p e n d s on the indiv idual 's iron status a n d the compos i t i on of the diet (factors enhanc ing or inhibit ing absorpt ion) . It h a s been genera l l y a g r e e d that the major factors enhanc ing non -heme iron absorpt ion inc lude asco rb i c a c i d , meat , poultry a n d f ish a n d organ ic ac i ds (citric, lact ic, mal ic , and tartaric ac ids) (Hal lberg, 1989 ; L y n c h , 1997) . E n g e l m a n n et a l . , (1998) invest igated the inf luence of meat on n o n - h e m e iron absorp t ion in a c r o s s - o v e r d e s i g n with 8, 43 -49 w e e k o ld infants a n d found that n o n - h e m e iron absorp t ion w a s signi f icant ly i nc reased ( 1 5 % from 9.9%) from the vegetab le mixture w h e n meat w a s a d d e d . T h e major factors that inhibit non -heme iron absorpt ion inc lude phytates, wh i ch are found in all c e r e a l s and s o y products , po lypheno ls in tea , cof fee, vege tab les and fruits, s o m e proteins (egg a lbumin a n d l egume protein) and s o m e inorganic e lements (calc ium) (Fai rweather-Tai t , 1989; F A C V W H O , 1988). Further, da ta a re ava i lab le to sugges t that 11 LITERATURE REVIEW sol id food feed ing patterns m a y interfere with the absorpt ion of iron f rom breast milk, and hence inf luence the iron status of the infant (Osk i and L a n d a w , 1980). Con t i nued research on ' food combina t ions ' that promote n o n - h e m e iron absorpt ion m a y better e luc idate the link be tween food mixtures that a re fed to infants and the absorp t ion of dietary iron (Fairweather-Tai t et a l , . 1995 ; F o x et a l . , 1998 ; F u c h s et a l . , 1993) . T h e genera l effects of diet compos i t i on on the relative bioavai labi l t iy of iron have been desc r i bed ( F A O / W H O , 1988). Diets have been d iv ided into low, intermediate, and high iron bioavai labi l i ty that c o r r e s p o n d e d to absorp t ion rates of about 5 % , 1 0 % , and 1 5 % respect ive ly (in the p r e s e n c e of low iron s tores) . M o n s e n et a l . , (1978) state that a diet with low iron bioavai labi l i ty h a s a high inhibitor content with f ew promoters in the fo rm of meat , f ish or asco rb i c ac id . Us ing the mode l desc r i bed by M o n s e n et a l . , (1978), the percen tage of iron abso rbed f rom a typical s ing le mea l f rom the C a n a d i a n diet is a s s u m e d to be 1 2 . 5 % (Health and Wel fa re C a n a d a , 1990). T h e r e c o m m e n d e d dietary iron intake for 5 - 12 month old infants is 7.0 mg /day a n d is der ived f rom the total iron requ i rement of 0.7 mg /day with a n a s s u m e d factor of 1 0 % for absorp t ion (Heal th a n d W e l f a r e C a n a d a , 1990) . Howeve r , the so l id f ood transi t ion diet of young infants ( 4 - 9 months) con ta ins predominant ly iron of low bioavai labi l i ty (5%) ( F A O / W H O , 1988; Y e u n g et a l , 1981). T h e fo l lowing f igure e m p h a s i z e s the effects of diet compos i t ion on the relative bioavai labi l i ty of iron f rom food a n d highl ights the 'vulnerabil i ty ' of infants to low iron status due to adequa te iron intake a n d absorp t ion f rom typical wean ing foods . 12 LITERATURE REVIEW High Bioavailability (>15%) Low Bioavailability (5%) -Whole wheat flour, beans, rice, corn P L U S Very small quantities of; -Meat and/or -Ascorbic acid Intermediate Bioavailability (10%) -Whole wheat flour, potatoes, beans, rice, corn P L U S some -Meat and/or -Ascorbic acid Generous quantities of; -Meat and/or -Ascorbic acid P L U S -White flour products (bread/pasta), Fruits and Vegetables Figure. 2. The influence of diet composition on the relative bioavailability of iron. Diets of low (5%), intermediate (10%), and high iron biavailability (>15%) are shown (adapted from FAC7WHO, 1988). An understanding of how complex meals are fed to infants and why mothers chose the feeding strategies that they do could facilitate an understanding of how to increase non-heme iron absorption through food combinations. However, research is lacking on the infant solid food feeding strategies that promote the consumption of an appropriate quantity of dietary iron from solid foods, or feeding strategies that might enhance the bioavailability of the non-heme iron present in the infant diet. 2.2.3. Dietary consumption patterns Very little information has been published on the food intake of Canadian infants during the second six months of life. Over the past 20 years there has been a definite trend away from the early introduction of solid foods. In the late 1970's, Clark et al., (1981) and Yeung et al., 13 LITERATURE REVIEW (1981) found that so l id food had been in t roduced to 7 8 % and 7 0 % of infants, respect ively, by 3 months of a g e . In the ear ly 1980 ' s , T a n a k a et a l . , (1987) a n d G r e e n e - F i n e s t o n e et a l . , (1989) reported a t rend to later introduct ion, with on ly 4 2 % and 3 3 . 8 % , respect ive ly , of infants in t roduced to so l id foods by 3 months of a g e . In a recent s tudy in V a n c o u v e r , this trend toward later introduction of so l id foods w a s even more apparent . W i l l i ams et a l . , (1996) found that only 7 . 8 % of infants in V a n c o u v e r had b e e n g iven iron-fortified infant ce rea l s before 4 months of age . Th i s trend to later introduction of so l id foods is more c lose ly a l igned with the current C a n a d i a n Pediat r ic Soc ie t y ( C P S ) Nutrit ion Commi t t ee recommenda t i ons a n d co inc ides with the soc ie ta l shift towards an i nc reased initiation and durat ion of b reas t - feed ing . Howeve r , Wi l l i ams et a l . , (1996) a l so found that iron-fortif ied ce rea l had not b e e n g iven to 6 . 7 % of the infants by 7 - 9 months of age , a n d mea ts , c h i c k e n or f ish had not b e e n g iven to 3 3 % , 2 4 % and 6 2 % , respect ive ly , of the infants by 9 months of a g e . Poss ib l y , the later introduction of h e m e iron conta in ing foods b e y o n d r e c o m m e n d e d a g e s in s o m e infants cou ld impact on iron status at 9 months of age . T w o s tud ies have reported that feed ing infants iron fortified ce rea ls for l ess than 3 months (G reene -F ines tone et a l . , 1989) or less than 6 months ( L e h a m n n et a l . , 1992) w a s assoc ia ted with an i nc reased risk of IDA. Howeve r , there a p p e a r s to be no pub l ished da ta on whether the mother 's know ledge or percept ions about the impor tance of feeding iron conta in ing sol id foods in f luences s u b s e q u e n t feed ing prac t ices . T h e last Infant Nutrit ion S u r v e y (1977-78) in C a n a d a found that a segmen t of the infant populat ion cou ld h a v e diets def ic ient in i ron ( Y e u n g et a l . , 1983) . T o a s s e s s the a d e q u a c y of dietary iron in takes, the m e a n iron intake w a s c o m p a r e d with the current r e c o m m e n d e d intake of 7 mg /day for infants 5 to 12 months of age . T h e probabi l i ty of iron def ic iency was then approx imated (b iochemica l da ta were not used) . T h e proport ions of 6, 8 , 1 0 , and 12 month o ld infants with an inadequate intake of iron were 3 5 % , 3 3 % , 3 7 % a n d 5 3 % , respect ively, and the probab le proport ions of infants with iron def ic iency a n e m i a were 2 1 % , 1 8 % , 2 0 % and 3 3 % , respect ive ly (Yeung , 1983). Howeve r , s i nce the iron prov ided by breast milk was not inc luded in the ana lys i s of the m e a n d ie tary i ron intake, the v a l u e s a re m o s t l ikely h igher than wou ld b e expec ted . F r o m 3 - 1 0 months of a g e , 7 0 % to 9 3 % of the infants in this s tudy were receiv ing 14 LITERATURE REVIEW infant ce rea ls and the amoun t they c o n s u m e d a v e r a g e d 18 - 20 g rams per day. Th i s amount of ce rea l wou ld contr ibute about 7 0 % of the total iron requi rement , a s s u m i n g 1 0 % absorpt ion ( 7 0 % of 7 mg is 4.9 m g of dietary iron). Howeve r , if the n o n - h e m e cerea l iron w a s abso rbed at only 5 % rather than 1 0 % only about 3 0 % of the iron requirement ( 0.7 m g per day) wou ld be met. Y e u n g (1983) s u g g e s t e d that the ma in c a u s e of the high p reva lence of iron def ic iency a s the infant g rew o lder w a s the rep lacement of iron-fortified infant ce rea ls with adult ce rea ls and table foods , wh ich con ta in on ly 5 0 - 3 5 % of the iron found in infant c e r e a l s . Howeve r , the lack of da ta o n the amoun t of iron a b s o r b e d f rom iron-fortified infant ce rea l s , poss ib le adve rse effects of cows ' milk in the infant diet, a n d the amoun ts of ce rea l c o n s u m e d over t ime limit the interpretation of populat ion da ta on dietary iron intake. M o r e recent ly, seve ra l s tud ies have s u g g e s t e d that there are d i f ferences in the sol id food consump t i on pat terns b e t w e e n breast - fed infants a n d infants fed formula . Wa l te r et a l . , (1993) reported that formula- fed infants c o n s u m e d 2 7 g m s , 3 0 g m s , and 3 1 g m s / d a y of infant ce rea l c o m p a r e d with 10gms , 2 0 g m s , and 2 3 g m s / day by breast- fed infants at 5, 6, and 7 months of a g e , respect ive ly . Further, the ce rea l intake w a s a l s o signi f icant ly different be tween the 2 groups at 8 months of age . It s e e m s poss ib le that the cumula t ive impact of lower infant ce rea l consumpt ion cou ld i nc rease the r isk of iron def ic iency a m o n g breast - fed infants. Longi tud ina l s tud ies to s h o w this, however , a re lack ing . He in ig et a l . , (1993) a l so found d i f ferences in so l id food feed ing be tween breast - fed a n d formula- fed infants, but the d i f ferences were in introduction of so l id foods 'other 1 than c e r e a l s , that a re important to iron nutrition. At 9 months of age , meats , f i sh , and poultry had b e e n in t roduced to 8 7 % of the formula- fed infants but to only 5 2 % of breast- fed infants. Fur thermore , 6 3 % of the breast - fed infants c o m p a r e d with 3 1 % of fo rmula- fed infants had been g iven dai ry products at 9 months . A s wou ld be expec ted , these d i f ferences d i sappea red by 12 months (Hein ig et a l . , 1993). In summary , the ava i lab le l iterature sugges t s that infants m a y be fed so l id food differently depend ing on whether the infant is breast - fed or bott le-fed with infant formula . Breas t - fed infants appea r to c o n s u m e less iron-fortif ied infant ce rea l , to be in t roduced to h e m e iron s o u r c e s later, a n d to be in t roduced to dairy products (which inhibit iron absorpt ion) soone r than formula- fed 15 LITERATURE REVIEW infants. It is not clear from the available literature why these differences occur. In order to develop nutrition education strategies to prevent iron deficiency a greater understanding of the factors that influence the solid food feeding practices as well as the perceptions, attitudes and beliefs of mothers, is needed. The possibility that early exposure to the varying flavors in mother's milk rather than the constant unvarying flavor of formula affects later food preferences, the development of food habits and the acceptance of new foods at weaning or later is a new and exciting area of research. Infant acceptance of iron-fortified infant cereal, as a transitional food, is pivotally important to its efficacy as the primary source of dietary iron for infants during the transition period ( 4 - 9 months). Mennella and Beauchamp (1998) stated that infants are clearly not passive receptacles for early flavor experiences. Studies on 'taste' generally agree that infants have the ability to detect sweet tastes very early and there appears to be an innate preference for sweet tastes and rejection of bitter tastes. Less is known about infant texture preferences. Food taste and texture preferences may be key factors in the infant's solid food selection patterns and in the quantity of food that is consumed. Sullivan and Birch (1994) have reported information on infant acceptance of first solid foods with respect to milk feeding method and repeated exposure on acceptance of the same or similar foods. These authors found that after repeated exposure, all infants (n=36) increased their intake of vegetables. In addition, the finding that breast-fed infants had a greater intake of vegetables than formula-fed infants led Sullivan and Birch (1994) to suggest that breast-feeding facilitates the acceptance of solid foods. However, Birch et al., (1998) found that the number of feedings needed to increase intake of a 'novel' similar food in 4 to 7 month old infants (n=36) nearly doubled after only one exposure. The infants were much less responsive to a 'novel' different food. This finding suggests that infants can be particularly sensitive to small changes in food flavors. Mennella and Beauchamp (1997) reported that infants consumed significantly more cereal if the cereal was prepared with the mother's milk, and ate at a faster rate than when the cereal was prepared with water. Further, 30 minutes later the infants continued to prefer the milk- cereal combination over the water-cereal combination. Observation of videotaped infant cues 16 LITERATURE REVIEW a lso s h o w e d mi lk -cerea l mixture p re fe rences . T h i s s tudy sugges ts that the ce rea l preparat ion method (i.e., al ter ing f lavors) in f luenced the infant 's a c c e p t a n c e of the ce rea l . S t e p h e n s o n et a l . , (1994) c o m p a r e d the ef fects of feed ing a low-densi ty porr idge (2.15 kJ/g) , a thick h igh-densi ty porr idge (4.09 kJ/g) , and an a m y l a s e reduced v iscos i ty porr idge in 15 non- breast- fed infants of 7 - 15 months of age . A l though the m e a n dai ly consumpt ion of the th ickened porr idge w a s signi f icant ly lower, the da i ly ene rgy intake was signif icant ly higher. Further, the mea l durat ion w a s a lmost twice a s long with the thick porr idge mea l c o m p a r e d with the low-densi ty porr idge. S i n c e the ' th inned' v iscos i ty porr idge did not i nc rease energy intake, these authors sugges t s imp ly mak ing wean ing foods th icker and add ing s u c h foods a s oi l , or peanut butter c a n be u s e d to inc rease the energy dens i ty of food ea ten . Th i s s tudy sugges t s that the texture, in addi t ion to the f lavor, of the food c a n in f luence ce rea l consumpt ion . C o h e n et a l . , (1995) reported that de lay ing the introduction of comp lemen ta ry foods until 6 months w h e n c o m p a r e d with introduction at 4 months did not affect appeti te or food a c c e p t a n c e a m o n g exc lus ive ly breast - fed infants w h e n s tud ied later at 9 and 12 months of age . T h e r e were no d i f ferences found in the breast - feeding f requency , the amount or number of foods c o n s u m e d at the m idday m e a l , the amoun t of food of fered that w a s c o n s u m e d , the usua l dai ly number of mea l s and s n a c k s , the number of food groups c o n s u m e d , or the overal l food a c c e p t a n c e sco re at 9 and 12 months of a g e . Howeve r , the interpretation of this da ta is l imited s i nce the infants' food responses dur ing the transi t ion per iod f rom 4 to 9 months w a s not desc r i bed . T h e verba l or non-verba l c u e s wh ich infants d i sp lay w h e n offered food and dur ing feed ing are responses to a c o m p l e x set of factors (for e x a m p l e , deve lopmen ta l read iness , food p re fe rences , sat iety or t i redness) . Further, feed ing d y n a m i c s m a y p lay a crit ical role in food a c c e p t a n c e and thus consumpt ion pat terns. Sat te r (1990) has noted that effect ive feed ing inc ludes a l lowing the infant to de te rmine food t iming, amount , p re fe rence, pac ing , eat ing capabi l i ty, and provid ing the opportunity to exp lo re the food . S h e states that suppor t ive posi t ive feed ing d y n a m i c s are important for prevent ion of feed ing p rob lems. Sat ter (1990) has charac te r i zed infant deve lopmenta l pr inc ip les that gu ide feed ing ove r the first 36 months of life. Of note, the 'separat ion indiv iduat ion' s tage that beg ins at about 6 months of age is a deve lopmenta l s tage 17 LITERATURE REVIEW when infants "exert increasing control over their environment and the people in if . Satter (1990) has described 13 parental behaviors that support infant opportunities to explore, yet give structure and limits to feeding. These behaviors appear to focus around the concepts of engaging feeding behaviors rather than overwhelming behaviors, appropriate pacing of feeding, exploring, sensitivity to food preference and satiety cues, and giving control and support. Although these behaviors seem common sense, infant feeding can be both complex and challenging for mothers during the transition period. The available data suggest that the 'interactional' characteristics of the feeding relationship could cause poor feeding dynamics and consequently inadequate dietary intake. Research is lacking on determinants of mothers' solid food feeding behaviors, such as the characteristics of the feeding relationship. 2.2.4. Breast-feeding and weaning practices Breast-feeding is considered the optimal method of feeding infants up to 2 years of age and beyond, with the introduction of complementary solid foods recommended to begin starting at 4 - 6 months of age (CPS, 1998). Although the breast-feeding initiation and duration rates in Canada have both increased in the last 25 years they still fall short of the current recommendations to exclusively breast-feed for at least 4 (CPS, 1991; C P S , 1998; Vancouver Health Dept. 1993), or 6 months (O'Brian et al., 1998; WHO/UNICEF, 1989). Data on breast- feeding trends in Canada are available from the national study from 1963 to 1982, as well as from local and regional studies. McNally et al., (1985) summarized the results of 9 cross-sectional rates in breast-feeding trends in Canada from 1963-1982. In 1963, only 38% of women initiated breast-feeding compared with 75% in 1982. A study during 1984-85 by Tanaka and colleagues (1987) found that 88% of mothers in metropolitan Toronto initiated breast-feeding. The National Population Health Survey (NPHS) and the National Longitudinal Survey of Children and Youth (NLSCY), both conducted in the early 1990's, found initiation rates of 73% among a random sample of women across Canada (Maclean and Miller, 1998). Williams et al., (1996) found that although about 83% of mothers in Vancouver started to breast-feed in hospital, only 30% of mothers exclusively breast-fed until 6 months and only 18% were still breast-feeding at 9 months 18 LITERATURE REVIEW postpar tum. T h e definit ion 'exc lus ive ly 1 breast - fed in the latter s tudy w a s breast- feeding with no bott le- feeding of fo rmula or c o w s ' milk. Breas t - feed ing durat ion rates have a lso inc reased f rom 1 4 % to 4 4 % breast - feed ing to 4 months and f rom 7 % to 3 1 % breast - feeding to 6 months, f rom 1963 to 1982, respect ive ly (McNa l l y et a l . , 1985). A l though breast - feed ing initiation rates in C a n a d a have improved dramat ica l ly dur ing the last 20 yea rs , the number of mothers breast- feed ing to 6 mon ths of a g e h a s s t a y e d at about only 3 0 % s i n c e the ear ly 1 9 8 0 ' s , (McNa l l y et a l . , 1985 ; T a n a k a et a l . , 1987; Wi l l i ams et a l . , 1996). W h e t h e r so l id food feed ing pract ices impact b reas t - feed ing p rac t i ces , in part icular, b reas t - feed ing durat ion is unc lear . T h e proport ion of infants fed so l id foods before 4 months of age has d e c r e a s e d substant ia l ly ove r the past 20 yea rs . In 1977 - 78 , the med ian a g e at wh ich mothers in t roduced sol id foods w a s less than 2 months , with 6 5 % introducing sol id foods by 1 month of a g e ( T a n a k a et a l . , 1987) . In contrast , by 1984 -85 , the med ian a g e for so l id food introduction w a s 4 months . B y 6 months of age , about 9 0 % of infants in s tud ies be tween 1977 and 1996 were receiv ing infant ce rea l ( T a n a k a et a l . , 1987 ; W i l l i ams et a l . , 1996; Y e u n g , 1981). G r e e n e - F i n e s t o n e et a l . , (1989) reported that 3 t imes more infants of low s o c i o e c o n o m i c s tatus ( S E S ) rece ived so l ids prior to 3 months of age w h e n c o m p a r e d to infants of a h igh S E S . T h e s e authors a lso s h o w e d that mothers who did not b reas t - feed in t roduced so l ids about 1 month ear l ier than mothers who breast- fed and bott le-fed, or w h o on ly breast - fed . Th i s sugges t s a link be tween lower educat ion leve l , lower i ncome a n d s o c i o - e c o n o m i c s ta tus, bott le- feeding a n d earl ier introduction of so l id foods (Beaudry et a l . , 1989; B e r g e r m a n et a l . , 1979; G r e e n e - F i n e s t o n e et a l . , 1989; Stewar t et a l . , 1987) . N u m e r o u s s tud ies have e x a m i n e d factors that a re a s s o c i a t e d with a mother 's dec is ion to b reas t - feed a n d to w e a n . T h e s e s tud ies h a v e identi f ied d e m o g r a p h i c factors s u c h a s materna l a g e , educa t ion , i ncome, marital s ta tus, ethnici ty and psychosoc ia l var iab les s u c h as att i tudes, s t ress and suppor t a s important determinants of infant feed ing prac t ices . S u c c e s s f u l breast- feed ing invo lves a c o m p l e x interact ion of factors that a re rec iprocal ly de termined by internal pe rsona l and soc io -env i ronmenta l fac tors . T h e internal pe rsona l factors that m a y determine breast - feed ing durat ion inc lude; cogni t ive/af fect ive (e.g., know ledge , att i tudes, bel iefs), ou t come 19 LITERATURE REVIEW expecta t ions (e.g., best for baby) , se l f -ef f icacy (e.g. , con f idence , prev ious exper ience) , b io logical (e.g., age) or psychosoc ia l (e.g., embar rassmen t ) (Wi l l iams et a l . , 1999). T h e soc io - env i ronmenta l factors that m a y inf luence breast - feed ing durat ion inc lude; institutional (e.g., heal th ca re prac t ices , suppor t ive work p lace env i ronments and pol ic ies) , soc ia l (e.g., suppor t ive par tner / fami ly /dynamics) , soc io -demograph i c (e.g., educa t ion , i ncome, ethnicity, marital status), phys ica l (e.g., d iscomfor t or pa in , t i redness) a n d others (e.g., d i s tance f rom work) (Wi l l l iams, et a l . , 1999). Howeve r , resea rch is lack ing on the internal pe rsona l and/or soc io -env i ronmenta l factors that de termine sol id food feed ing prac t ices or how breast - feeding pract ices might in f luence so l id f ood feed ing prac t ices . T h e W o r l d Hea l th Organ iza t ion ( W H O / U N I C E F , 1989) h a s e m p h a s i z e d the impor tance of suppor t ive env i ronments in hospi ta ls and the commun i ty to promote both i nc reased initiation a n d durat ion rates of breast - feed ing. T o implement their r ecommenda t i ons heal th ca re institutions are a s k e d to put in p lace pol ic ies that comp ly with the "10 s teps to S u c c e s s f u l Breas t - feed ing" ( W H O / U N I C E F , 1989) and T h e W H O International C o d e of Market ing of Breast -mi lk Subst i tu tes ( W H O , 1981). A l though more support ive breast - feed ing work env i ronments (Katcher and L o n e s e , 1985 ; K e a r n e y a n d Cronenwet t , 1991 ; M o r s e et a l . , 1989) and soc ia l suppor t ( R o u s s e a u , 1982) m a y enab le mothers to breast feed longer, a better unders tand ing of how mothers feed their infants so l id foods be tween 4 - 9 months of a g e m a y a lso promote breast - feed ing durat ion s i nce the l iquid a n d so l id food pract ices are s o c lose l y intertwined dur ing the transi t ion per iod. P r e v i o u s s tud ies h a v e s h o w n that b reas t - feed ing is of ten d iscont inued ear ly d u e to insufficient milk (Henly, 1995 ; M a c l e a n and Mil ler, 1998 ; W i l l i ams et a l . , 1999) and mothers ' percept ions of infant hunger c u e s (Schwar tz and E v e r s , 1998). A recent s tudy in V a n c o u v e r that e x a m i n e d the factors inf luencing mothers ' dec i s i ons to w e a n , reported that the main reasons for wean ing before 3 months were the mother 's conce rn for the baby ' s nutrition, and be ing uncomfor tab le with b reas t - feed ing . T h e ma in reasons for d iscont inu ing breast - feeding at 3 to 6 months were the n e e d to return to work, conce rn about the baby ' s nutrition and conce rn about milk supply . In contrast , mothers who w e a n e d after 6 months , did s o primari ly b a s e d on their n e e d to return to work and their pe rsona l cho i ce (Wi l l iams et a l . , 1999). T h e ava i lab le da ta are 20 LITERATURE REVIEW not c lea r if the mother 's c o n c e r n s about infant hunger, nutrition and milk supp ly are related, in s o m e way , to the so l id food feed ing p r o c e s s rather than i s s u e s spec i f i c to breast- feeding a lone . A better unders tand ing of how mothers ' f e e d infants so l id foods dur ing the transit ion p r o c e s s might further our unders tand ing of the in f luence of sol id foods on the liquid diet, or al ternately the in f luence of l iquid foods on the so l id food diet. N u m e r o u s s tud ies h a v e used pr imari ly a quanti tat ive app roach (e.g., survey) to examine the demograph i c and soc ia l cor re la tes of mothers ' breast - feeding behav io rs . T h e survey method is l imited in its abil i ty to identify the m e a n i n g of comp lex i ssues , s u c h a s breast - feed ing, b e c a u s e the r e s p o n s e formats are c l o s e e n d e d a n d have usual ly been der ived f rom the research literature that is not necessa r i l y relevant to the context of the mother 's s i tuat ion. A l though the su rvey method is important for identifying d e m o g r a p h i c predictors of breast - feeding cho i ces , only a part ial unders tand ing of the 'b reast - feed ing ' exper ience c a n be expec ted . M a c l e a n (1990), however , sugges t s an al ternat ive f ramework for thinking about the breast - feeding exper ience . Us ing exper ient ia l ly f o c u s e d r e s e a r c h , mothers ta lked in-depth about the var iety of r easons that contr ibuted to their dec is ion to w e a n ear ly. O n e comp lex set of factors that evo lved w a s l inked to the overwhelming experience of having a baby (turbulent emot ions and vulnerabi l i ty). Ano ther set of fac tors w a s l inked to the cultural context (the cumula t i ve work of mother ing a n d conf l ict ing soc ia l va lues) . Last ly , changes in self identity (self worth, soc ia l iso lat ion, fee l ings of reward and anxiety, phys ica l d iscomfor t or pa in , s e n s e of t ime) were c lose ly l inked to mothers ' breast- feeding expe r i ences and ear ly wean ing . T h e s e t h e m e s m a y a l so impact the ' transit ion exper ience ' and in f luence the a g e sol id foods are in t roduced, a s wel l a s how sol id foods are fed to 4 - 9 months old infants. Fur ther a d v a n c e s in unders tand ing wean ing prac t ices might c o m e f rom a deepe r unders tand ing of how mothers expe r i ence the so l id food feed ing p r o c e s s . 2.3. Infant feeding guidelines Recen t l y , three expert g roups : the C a n a d i a n Paed ia t r i c Soc i e t y Nutrit ion Commi t tee , Diet i t ians of C a n a d a and Hea l th C a n a d a have p repared a Nat iona l s ta tement on nutrition for heal thy term infants f rom birth to 24 months of a g e ( C a n a d i a n Paed ia t r i c Soc ie ty , 1998). It is 21 LITERATURE REVIEW important to note, however , that the infant feed ing recommenda t i ons are b a s e d on scienti f ic ev i dence w h e n it is ava i lab le , but a re o therwise b a s e d o n " a c c e p t e d c o m m o n prac t i ces" . T h e gu ide l ines prov ide heal th ca re p ro fess iona ls with current rel iable nutrition information on breast- feed ing , al ternate mi lks, transit ion to so l id foods , the prevent ion of iron def ic iency a n e m i a and other top ics ( C P S , 1998). T h e gu ide l ines are u s e d by many sec to rs , including industry for preparat ion of educat ion mater ia ls and c o m m e n t s on food packag ing . T h e popular p ress a lso u s e s this informat ion (i.e., parent ing m a g a z i n e s ) . Hosp i ta l s a n d phys i c ian of f ices, a s wel l a s publ ic heal th depar tments provide this information for mothers . A s a result, mothers rece ive infant feed ing information through m a n y c h a n n e l s . Howeve r , the infant feed ing gu ide l ines d o not focus on the pract ica l i s sues a round how to f eed so l id foods . Wi th regards to the transit ion to so l id foods , the current feed ing gu ide l ines for heal thy te rm infants ( C a n a d i a n Paed ia t r i c Soc ie ty , 1998) state that " infants be tween 4 a n d 6 mon ths of a g e are phys io log ica l ly and deve lopmenta l l y ready for new foods , textures and m o d e s of feed ing" . T h u s , two spec i f i c r ecommenda t i ons are g iven . Mothers a re r e c o m m e n d e d to introduce comp lemen ta ry foods at 4 to 6 months of a g e to meet the infant's increas ing nutrit ional requi rements a n d for deve lopmen ta l n e e d s . S e c o n d , to prevent iron def ic iency, i ron-containing f oods s u c h a s iron-fortif ied c e r e a l s a re r e c o m m e n d e d a s the first f oods . In addi t ion, the work ing group r e c o m m e n d s that the ear ly u s e of w e a n i n g foods , that is prior to 4 months of age , m a y i nc rease the risk of iron deplet ion a n d a n e m i a s i nce iron absorpt ion f rom human milk is d e p r e s s e d w h e n the milk is in contact with other foods in the prox imal sma l l bowe l . Th i s s ta tement impl ies that the t iming of feed ing breast milk and sol id foods is important to iron absorp t ion . Fur ther , with regards to the prevent ion of iron def ic iency a n e m i a , the gu ide l ines state "iron def ic iency is p reventab le through appropr ia te feed ing c h o i c e s " . Consequen t l y , s ix r ecommenda t i ons are g iven , three perta in ing to the pr imary milk sou rce , two regard ing the a g e of introduction a n d durat ion of feed ing iron conta in ing sol id foods , and o n e refers to sc reen ing for IDA a n d supp lementa t ion with med ic ina l i ron. T h e first recommenda t ion is to cont inue exc lus ive breas t - feed ing for at least 4 months . T h e gu ide l ines r e c o m m e n d that mothers introduce comp lemen ta ry foods conta in ing iron at 4 to 6 months of a g e . T h e third recommenda t ion a d v i s e s 22 LITERATURE REVIEW that the preferred breast-mi lk subst i tute for infants w h o are not breast - fed or who are partial ly breast - fed is iron-fortified infant fo rmu las . T h e gu ide l ines r e c o m m e n d de lay ing the introduction of who le c o w ' s milk until the infant is 9 to 12 months of age . T h e fifth recommendat ion is to cont inue to offer iron-fortif ied foods b e y o n d 1 yea r of a g e to prov ide suff icient dietary iron for the infant. T h e last recommenda t ion is that whe re in formed parents c h o o s e not to adhere to these recommenda t ions , the infant shou ld b e s c r e e n e d for a n e m i a at 6 to 8 months of a g e a n d p rov ided with medic ina l iron d rops , if n e c e s s a r y ( C P S , 1998). In addi t ion to the Na t iona l gu ide l ines , Prov inc ia l infant f eed ing gu ide l ines have a l s o b e e n d e v e l o p e d . T h e current gu ide l ines for Br i t ish C o l u m b i a ( B . C . Minist ry of Hea l th , 1996), r e c o m m e n d feed ing sol id foods 1 - 2 t imes per day, f rom 4 to 6 months of age start ing with 1 t easpoon of iron-fortified ce rea l a n d inc reas ing to 4 t ab lespoons per day . F r o m 6 to 9 months , mothers are instructed to feed their infant so l id foods 3 - 4 t imes per day . Speci f ica l ly , the gu ide l ines r e c o m m e n d to feed infant ce rea l in the amoun t of 4 to 8 t ab lespoons daily, a s wel l a s introduce other iron conta in ing foods s u c h a s meat , f ish, and poultry start ing at 6 months of a g e (Append ix A ) . T h e wean ing recommenda t i ons c a n be cons ide red in three over lapp ing per iods: 1) the exclusive milk (breast or formula) feeding period, 2) the weaning period a n d 3) the per iod of a modified adult diet ( C a m e r o n et a l , 1990 ; E S P G A N , 1 9 8 1 ; Wha r ton , 1989; W H O , 1988). T h e concep t of 'over lapp ing per iods ' is i l lustrated by listing the p rogress ion of foods r e c o m m e n d e d for introduction into the infant diet, acco rd ing to age of the infant (i.e., 0 to 24 months) . T h e main publ ic heal th m e s s a g e s c o n v e y e d in the infant feed ing recommenda t i ons a re a) w h e n to introduce sol id foods , b) what f oods to int roduce a n d c) the feed ing p rogress ion . T h e feed ing p rogress ion refers to i nc reas ing the quant i ty a n d var iety of so l id f o o d s that the infant ea ts s o by about 1 year of age the infant is c o n s u m i n g a 'modi f ied ' adult diet. Howeve r , resea rch is lack ing on how mothers in the natural sett ing feed their infants so l id foods a n d what de termines their feed ing prac t ices . S o m e light m a y be s h e d on the c a u s e s of the p reva lence of iron def ic iency a m o n g infants by explor ing determinants of so l id food feed ing prac t ices that m a y inf luence the infant's 23 LITERATURE REVIEW consumpt ion of iron-fortified c e r e a l s . R e s e a r c h identifying the key behav iora l factors that in f luence the consumpt ion of iron conta in ing so l id foods by infants and thus poss ib ly contr ibut ing to the deve lopmen t of iron de f i c iency in the s e c o n d 6 months of life is lack ing. T h e concep tua l f rameworks n e e d e d for this type of behav iora l resea rch have not yet been fully art iculated in the l iterature. Further, so l id food feed ing prac t ices have not b e e n s tud ied us ing a qual i tat ive a p p r o a c h a n d , therefore, the infant f eed ing l i terature ref lects this g a p in knowledge . R e s e a r c h in this a r e a is n e c e s s a r y to bui ld f rameworks that c a n facil i tate the invest igat ion and unders tand ing of important behav iora l and cogni t ive factors that in f luence the feed ing of so l id foods , part icular ly t hose high in i ron, to infants dur ing the transit ion p r o c e s s . R e s e a r c h to gain a better unders tand ing of mothers ' so l id food feed ing prac t ices dur ing the transit ion per iod is, therefore, n e e d e d to a d d r e s s the g a p s in the current resea rch l iterature. 24 DESIGN AND METHODS Chapter III 3.1. Introduction to qualitative research design A n exploratory resea rch des ign w a s u s e d to invest igate mothers ' comp lementa ry so l id food feed ing expe r i ences . Th i s resea rch des ign w a s c h o s e n b e c a u s e quali tat ive resea rch c a n e x p a n d know ledge a n d theory about the infant so l id food feed ing p rocess in a natural context through learn ing about mothers ' pe rsona l day- to -day expe r i ences . Addit ional ly, qual i tat ive research h a s the mos t potent ial to identify a n d deve lop relevant concep ts on wh ich to bui ld hypo theses that a re t ime a n d context bound . Qual i ta t ive inquiry i nc reases unders tand ing of part ic ipants ' percep t ions a n d expe r i ences in their natural set t ing, providing resea rch f indings that a re relevant and pract ica l . A s a result, f indings c a n be very useful for informing nutrition, dietetic and publ ic heal th nurs ing pract ice. Further, qual i tat ive resea rch c a n be used to c reate new da ta gather ing techn iques to gu ide future resea rch . A qual i tat ive r e s e a r c h des ign has major d i f fe rences in methodolog ica l assump t i ons c o m p a r e d with a quant i tat ive resea rch des ign (C reswe l l , 1994; L inco ln and G u b a , 1985). Brief ly, qual i tat ive resea rch is descriptive in that the inquirer is interested in unders tanding how indiv iduals m a k e s e n s e of their pe rsona l expe r i ences , the cond i t ions that in f luence their ac t ions , and the c o n s e q u e n c e s of their ac t ions . T h e da ta are not, in the convent iona l s e n s e , quant i f iable. Theo ry or hypo theses in qual i tat ive resea rch a re not es tab l i shed a priori s i nce the focus of this resea rch is not to ver i fy o r falsi fy hypo theses us ing stat ist ical fo rmulas . Instead, the p r o c e s s of qual i tat ive resea rch is inductive and emergent. It is induct ive in that the inquirer, a s the pr imary da ta col lect ion and ana l ys i s tool , at tempts to bui ld abst rac t ions, concep ts , hypo theses a n d theor ies that a re t ime a n d context bound . It is emergen t in that the researcher 's interpretat ions (findings) a re a reconst ruct ion built f rom mult iple v o i c e s (Anne l ls , 1996; L inco ln and G u b a , 1985; Mer r i am, 1988). B e a r i n g in m ind , that the resea rche r is the pr imary da ta co l lect ion a n d ana lys i s instrument, qual i tat ive inquiry is value-bound (Munha l l a n d B o y d , 1993). A ' ref lexive' journal of evolv ing theoret ical th inking about the da ta is u s e d to unders tand how persona l expe r i ences m a y 25 DESIGN AND METHODS s h a p e the va lues and b i a s e s brought to the resea rch through the ' instrument' itself. T h e assumpt ion here is that the resea rche r ' s pe rsona l b i a s e s c a n not be e l iminated in qual i tat ive research , rather their in f luence on the da ta interpretat ions c a n be better unders tood and ref lected upon. Last ly , the crit ical i s sue of judging the resea rch p r o c e s s and product qual i ty differs be tween qual i tat ive and quanti tat ive resea rch . T h e four major criteria u sed in qual i tat ive resea rch for es tab l ish ing t rustwor th iness a re credibi l i ty, t ransferabi l i ty, dependabi l i ty a n d conf i rmabi l i ty (L incoln and G u b a , 1985) . T h e s e cr i ter ia a re u s e d ins tead of the tradit ional validity and reliability m e a s u r e s used in quanti tat ive resea rch b e c a u s e the da ta genera ted and the ana lys i s p rocedures in the qual i tat ive resea rch des i gns are dramat ica l ly different f rom that of quanti tat ive resea rch . G r o u n d e d theory methodo logy is used to col lect and a n a l y z e da ta on h u m a n behav ior . B e c a u s e of the a b s e n c e of pub l i shed resea rch o n mothers ' so l id food feed ing p rac t i ces dur ing the transit ion p r o c e s s , the var iab les relevant to the infant feed ing concep ts have not yet b e e n identif ied. There fo re , theory test ing is not the best a p p r o a c h . B e c a u s e of its un ique da ta col lect ion and ana lys i s p rocedures , the g rounded theory method has the most potential to identify concep ts a n d deve lop theory to exp la in bas i c feed ing prac t ices and patterns c o m m o n in mothers ' day- to-day act iv i t ies. Th i s is important, b e c a u s e it is poss ib le that mothers ' so l id food feed ing pract ices and feed ing pat terns over t ime m a y be related to the infant 's consumpt ion of iron conta in ing so l id foods . T h e g rounded theory method h a s its roots in the soc ia l s c i e n c e s , spec i f ica l ly in the symbo l i c interact ion tradit ion of soc ia l psycho logy a n d soc io logy . G r o u n d e d theory a s a methodo logy w a s or iginal ly d e v e l o p e d by two soc io log is ts , Ba rny G l a s e r and A n s l e m S t rauss , and pub l i shed initially in the sem ina l work, T h e D i scove ry of G r o u n d e d Theo ry (G lase r and S t rauss , 1967) . A g a i n , the pr imary a i m of g rounded theory is to genera te exp lanatory theory that furthers the unders tand ing of soc ia l a n d psycho log i ca l p h e n o m e n a . T h u s , g rounded theor ies a re sys temat ic s ta tements of p laus ib le re lat ionships (Denz in and L inco ln , 1994; Hu tch inson , 1993). T h e g rounded theory p rocedures prov ide a highly sys temat ic resea rch a p p r o a c h for the col lect ion a n d ana l ys i s of qual i tat ive da ta that differs s o m e w h a t from other qual i tat ive a p p r o a c h e s . First, greater e m p h a s i s is p laced on the deve lopmen t of theory (hypothesis) . 26 DESIGN AND METHODS S e c o n d , there is a n expl ici t manda te to str ive toward ver i f icat ion of the result ing hypo theses (statements of re lat ionships be tween concep ts ) . Th i rd , veri f icat ion is e m p h a s i z e d throughout the resea rch p r o c e s s , rather than in s u b s e q u e n t s tud ies . T h e c a u s a l - c o n s e q u e n c e mode l (G laser ,1978) a ids in identi fying and stat ing p laus ib le re lat ionships a m o n g the ca tegor ies that h a v e b e e n d i s c o v e r e d . T h e s e re la t ionships a re ver i f ied with the or iginal interview da ta . F ina l ly , within the emerg ing da ta se t , e m p h a s i s is p l aced o n deve lop ing 'conceptua l ly d e n s e ' theory ve rsus descr ip t ion . C o n c e p t u a l dens i ty refers to e n h a n c e d concep t deve lopment a n d the subsequen t integrat ion of re lat ionships be tween the c o n c e p t s (Denz in and L inco ln , 1994 ; Streubert a n d Carpen te r , 1995) . T h e mos t d is t ingu ish ing character is t ics of the g rounded theory p rocedu res a re : the cons tan t m a k i n g of c o m p a r i s o n s a c r o s s c a s e s , inc luding the sys temat i c ask i ng of generat ive a n d concept - re la ted ques t i ons , sys temat i c cod ing p rocedures , gu ide l ines for attaining concep tua l (not mere ly descr ipt ive) " d e n s i t y , var iat ion, concep tua l integrat ion, and subsequen t theoret ica l s a m p l i n g . Integration, here , m e a n s spec i fy ing condi t ions a n d c o n s e q u e n c e s of the p h e n o m e n o n be ing exp lo red (S t rauss and Co rb i n , 1990) . T w o m o d e l s that a r e fundamen ta l to d a t a ana l ys i s a r e u s e d in the g r o u n d e d theory me thod . T h e first is referred to a s a concept - ind ica to r mode l . A s i l lustrated in F igure 3 , the mode l a ids in the genera t ion of concep tua l c o d e s . In o rder to bui ld a concep t a n d its propert ies s lowly f rom the da ta , the ind icators a re constant ly c o m p a r e d to e a c h other and to the emerg ing concep t o n c e the concep tua l c o d e h a s b e e n g e n e r a t e d . I, I 2 h J 4 X 5 X 6 Legend CONCEPT ) I,, l2...- Indicators are compared to each other and the concept that is developing. (chunks of data such as words, phrases) Indicators F i g u r e 3. C o n c e p t - Indicator M o d e l (adapted f rom G l a s e r , 1978 , p.62). 27 DESIGN AND METHODS The second model that is used to guide the analysis is the causal-consequence model. This model aids in identifying the 'process' from the data. Process refers to a happening that takes place over time, such as a mother feeding her infant over time. The model aids in organizing the stages, phases, progressions, shaping or transitions of the phenomena so that the process can be conceptualized. What causes or makes the process move forward, backward or remain static are then investigated. Hence, the context, consequence(s), cause(s), and conditions of some action are discovered. This set of procedures also aids in making connections between the concepts and the higher order of more abstract categories. The model is illustrated in Figure 4. The context represents the set of conditions within which the action/interactional strategies are taken. Conditions are events or incidents within the context that influence the phenomenon. The causal conditions identify events or incidents that lead to the occurrence or development of a phenomenon, whereas intervening conditions are structural conditions that are contingent or conditional, meaning that they facilitate or constrain the strategies taken within a specific context. The phenomenon (A) is the central idea, event or incident about which a set of actions, or interactions, are directed at managing, or to which the set of actions is related. The consequences are the outcomes or results of the action and interaction. The covariance is the individual variation between the people. The arrows in the model indicate the direction or movement of the variables described above (Strauss and Corbin, 1990). Context Cause(s) ^ Phenomenon ^ Consequence(s) A t t t Covariance ^ T : Contingent Figure 4. The Causal-Consequence Model (adapted from Glaser, 1978 p.74) 28 DESIGN AND METHODS T h e 4 cri ter ia s u g g e s t e d for es tab l ish ing t rustworth iness in qualitative resea rch are ; credibil i ty, transferabi l i ty, dependab i l i t y and conf i rmabi l i ty (L incoln and G u b a , 1985). T h e credibi l i ty of interpreting the r esea rch da ta is e n h a n c e d through severa l p rocedures . A ref lexive journal that inc ludes a deta i led d ia logue about the m e a n i n g s of the data being a n a l y z e d and a descr ip t ion of how the ana lys i s evo l ved , with the cod ing p rocedures , g ives s o m e insight into how f ind ings were interpreted ove r the ana lys i s p r o c e s s . A journal a l so a ids in deve lop ing the ana lys t ' s ski l ls (i.e., theoret ica l sensit iv i ty). Ex te rna l c h e c k s done during the ana lys is of the da ta a id in 'ba lanc ing ' interpretat ions on concep ts , ca tegor ies and the relat ionships that a re concep tua l i zed . F e e d b a c k f rom peers on da ta interpretation improves the const ruc t ions. Negat ive c a s e s of s i tuat ions, even ts or expe r i ences shou ld be identif ied throughout the ana lys i s . T h e identif ication of negat ive c a s e s k e e p s the ana l ys i s b road and faci l i tates the identi f icat ion of contextual factors that m a y in f luence the p h e n o m e n o n that wou ld otherwise be lost. Pers is ten t , sys temat ic ana lys i s p rocedu res are essen t ia l to a l low not only identif ication of the most relevant i s s u e s , but for t h e m to be a n a l y z e d in detai l . In th is way , s c o p e and depth of ana l ys i s c a n b e a c h i e v e d . In-depth interv iews prov ide a m p l e da ta to obta in concep tua l densi ty of the emerg ing ca tegor ies , but it is the ana lys t , who by us ing a sys temat i c procedure d iscovers m e a n i n g f rom the da ta (reconstruct ion of mult iple vo ices ) . In qual i tat ive r e s e a r c h , transferabi l i ty is the term used instead of external val idity to desc r i be the d e g r e e to w h i c h the f indings c a n be app l i ed in other sett ings, or to other g roups of peop le . S i n c e it is not poss ib le in qual i tat ive resea rch to state statist ical con f idence limits to represent the externa l val idi ty of resul ts, 'thick' descr ip t ions of the interview data and the part ic ipant charac ter is t i cs a re p rov ided . T h i s a l l ows the a u d i e n c e to judge the transferabi l i ty of the s tudy f indings to o ther s i tuat ions or popu la t ions . T h e third cr i ter ia p r o p o s e d by L inco ln and G u b a (1985) is dependabi l i ty . T o ensu re f indings are d e p e n d a b l e an eva luat ion of the resea rch p r o c e s s is p roposed . A se r ies of documenta t ion p rocedu res are fo l lowed to a id in the da ta organizat ion, the ana lys is p rocedures and the ana lys i s itself. T h e dependabi l i ty .of f indings c a n be judged f rom these p rocedures . 29 DESIGN AND METHODS T h e a im of the confirmabil i ty cr i ter ia is to eva lua te the research product, the da ta , f indings, interpretat ions and recommenda t ions . T h e da ta obta ined f rom in-depth interviews are very ' r ich' and thus, the descr ip t ions and concep tua l i za t ions of human expe r iences shou ld reflect this r i chness . T h e resul ts of a quali tat ive s tudy c a n be j udged in light of the numerous procedures fo l lowed to p romote high qual i ty da ta m a n a g e m e n t , da ta ana lys is a n d interpretive integrat ion. S t r a u s s a n d C o r b i n (1990) have out l ined a doub le se t of cri teria fo r judg ing a g rounded theory study. T h e gu ide l ines these authors sugges t cen ter a round two componen t s , the resea rch p rocess and the empi r ica l grounding of the theoret ica l f ind ings. Brief ly, S t r a u s s and Co rb in (1990) eva luate the r esea rch p r o c e s s through examinat ion of the s a m p l e se lec t ion cr i ter ia, ca tegor ies that e m e r g e d a n d h o w they were fo rmed, theoret ical samp l i ng p rocedures , hypothes is format ion and test ing, a n d co re ca tegory se lec t ion . In addi t ion, the grounding of the theoret ical f indings is b a s e d on the examina t ion of the degree to wh ich the identi f ied concep ts a re g rounded f rom the data , rather than f rom conjecture. T h e deve lopmen t of concep tua l l inkages, the inc lus ion of variat ion into the theory, a n d e m p h a s i s on ' p rocess ' that identif ies and spec i f ies c h a n g e to bui ld the concep tua l dens i ty n e e d e d to go beyond descr ip t ive ana lys i s , a re all cri t ical to a g rounded theory study. T h e da ta c a n a l s o be a n a l y z e d macroscop ica l l y . Th i s inc ludes s o m e deg ree of ana lys is of the greater s o c i a l , env i ronmenta l a n d institut ional fac tors that in f luence indiv idual behavior . Last ly , the resea rch is eva lua ted on if, or to what extent the f indings a p p e a r signif icant f rom the perspec t i ve of contr ibut ion to know ledge , theory, tool deve lopment , pract ice or other relevant endpo in ts (L inco ln , 1995). 3.2. Design and Methods A qual i tat ive r esea rch des ign w a s u s e d to s tudy mothers ' comp lemen ta ry so l id food feed ing prac t ices dur ing the liquid to so l id food transit ion per iod that usual ly occu rs when the infant is 4 - 9 months of a g e . A g rounded theory me thodo logy was used to gu ide da ta col lect ion and ana lys is of h u m a n behav ior . In addi t ion to the interv iews, an infant-feeding quest ionna i re 30 DESIGN AND METHODS was developed to gather additional information to complement the qualitative data. Statistical quantification of questionnaire responses was not the focus of the research, nor would it be appropriate with the sample size used. The research design was cross-sectional. A convenience sample of mothers who were in the process of weaning their infants to solid foods (transition stage) was recruited. Data on current as well as retrospective feeding experiences were collected. Mothers were asked to articulate their solid food feeding practices over time (from the age solid foods were first introduced to the present time) to gain a more in-depth understanding of the solid food feeding process. 3.2.1. Ethics The study protocol and procedures were approved by the University of British Columbia Behavioural Sciences Screening Committee for Research Involving Human Subjects (Appendix B). Written informed consent was obtained from each participant before the interview session began. The research student explained the purpose of the study and the data collection procedures to each mother. The mother was then asked to read the consent form (Appendix C) and sign two copies if she agreed to participate in the study. One consent form was kept for research records and the other was given to the participant. The research student explained how confidentiality and anonymity in all oral and written research reports would be achieved. Participants were informed that, at any time during the interview or later, any written or taped information could be erased if they so chose. 3.2.2. Study participant inclusion criteria Criteria for inclusion in the study were that the infant was healthy and born at term (born greater than or equal to 37 weeks gestation) gestation, and had no disease or recurrent infections that could affect feeding solid foods or appetite. Mothers were breastfeeding or formula feeding. The participants recruited were residents of the City of Vancouver, were Caucasian and were fluent in English. Only mothers who were fluent in English were recruited because the researcher 31 DESIGN AND METHODS w a s only f luent in Eng l i sh and in-depth interviewing w a s a pr imary componen t of the research des ign . 3.2.3. Participant recruitment Pub l i c heal th nu rses facil i tating infant group c l in ics were a p p r o a c h e d face- to- face about the research project a n d were a s k e d to help recruit mothers who met the s tudy inc lus ion cri teria. Pub l ic heal th nu rses int roduced the resea rch s tudent to mothers who were at tending an infant group cl inic a n d who had infants within the se lec t ion cr i ter ia. T h e student then briefly exp la ined the resea rch project. If the mother w a s in terested in part ic ipat ing, s h e w a s a s k e d for her h o m e phone number for the student to contact her later. T h e potential part ic ipants were te lephoned and the s tudy p rocedu res were exp la ined . A recrui tment check l is t w a s used to faci l i tate appropr iate part ic ipant se lec t ion (Append ix D) . Interview s e s s i o n s were s c h e d u l e d at the part ic ipant 's c o n v e n i e n c e . T w e l v e mothers part ic ipated in the study. T w o mothers were recruited through pe rsona l referral. T e n mothers were recrui ted with the a s s i s t a n c e of publ ic heal th nurses at commun i ty cen te rs . F o u r recrui tment s i tes were used for this study. F r o m the 10 mothers who were recrui ted f rom the publ ic heal th commun i t y cen te rs , 2 we re f rom the F a l s e C r e e k C o m m u n i t y Cen te r , 3 were f rom the St . J a m e s C o m m u n i t y Cen te r , and 5 mothers were recruited f rom the U . B . C . Infant Drop-In Cen te r . T h e r e we re no part ic ipants f rom the fourth si te: U . B . C Little G o s l i n g s D a y c a r e . A n addi t ional 'potent ia l ' part ic ipant, recruited f rom the U . B . C . Infant Drop-In, dec l i ned after seve ra l r eschedu led interview t imes. 3.3. Data Collection Data were co l lec ted us ing two me thods ; interviews and ques t ionna i res . T h e total interview s e s s i o n took f rom 65 to 120 minutes to comp le te , but a v e r a g e d about 90 minutes in length. First, e a c h part ic ipant comp le ted a 30 -45 minute tape- recorded semi-s t ruc tured interview. Par t ic ipants then comp le ted a structured interview (infant feed ing pract ices quest ionnai re) that took a n addi t iona l 3 0 - 4 5 minu tes . T h e infant feed ing prac t ices quest ionna i re w a s on ly fully deve loped after the third interview , thus on ly the last 9 part ic ipants comp le ted the quest ionnai re . 32 DESIGN AND METHODS T h e interview s e s s i o n s c o n c l u d e d with the part ic ipant fil l ing out a conf ident ia l pe rsona l and demograph ic ques t ionna i re that took a further 5-10 minutes. Al l of the interviews, except one , were comp le ted in the mother 's home . O n e interview w a s comp le ted at a quiet cof fee shop se lec ted by the mother . 3.3.1. S e m i - s t r u c t u r e d interview g u i d e T h e interview s e s s i o n s b e g a n with a d i s c u s s i o n introducing the research topic. T h e warm-up d i scuss i on is i l lustrated in the interview gu ide be low. T h e mothers were e a c h a s k e d 5 genera l ques t ions that gu ided the conversa t ion onto the resea rch topic (Munha l l and B o y d , 1993). T h e quest ions we re d e s i g n e d to obtain information about the mother 's sol id food feed ing pract ices (i.e., her ac t ions) , a n d on her percept ions (her construct ions) o v e r t i m e . Interview g u i d e • W a r m - u p d i s c u s s i o n ( W h e n w a s your baby born? I a m interested in unders tand ing more about the infant wean ing p r o c e s s , c a n you tell m e about your expe r iences feed ing your baby so l id foods) . Guiding Quest ions: 1. C a n y o u tell m e about what the infant w e a n i n g p r o c e s s is l ike? O r tell m e about your expe r i ence with the infant w e a n i n g p r o c e s s (what is it l ike)? 2. W h a t diff icult ies have you encoun te red (if any)? i.e. Fami ly / f r iends/baby/hea l th ca re p ro fess iona ls 3. W h a t is work ing wel l for y o u ? 4. W h a t wou ld you tell a new mother about the wean ing p r o c e s s ? 5. W h a t wou ld you tell heal th ca re p ro fess iona ls about the wean ing p r o c e s s ? 33 DESIGN AND METHODS 3.3.2. Infant feeding practices questionnaire T h e quest ionna i re w a s deve loped us ing c o n c e p t s from the review of current literature and through f e e d b a c k f rom 4 infant nutrition and /o r su rvey des ign exper ts . T h e f eedback provided by t h e s e exper ts w a s u s e d to rev ise the ques t ionna i re . T h r e e mothers not invo lved in this s tudy prov ided f e e d b a c k o n the clarity of the ques t i ons a n d the format. T w o quest ion formats were deve loped for the quest ionna i re . S ing le r e s p o n s e a n d short answe r quest ions we re u s e d to obtain da ta on the mother 's present feed ing p rac t i ces a n d percept ions. O the r ques t ions were deve loped to elicit mult iple r esponses on feed ing p rac t i ces that had been u s e d ove r t ime, for the pu rpose of obta in ing d a t a o n the c h a n g e s in t he feed ing p r o c e s s accord ing to infant a g e . A s u m m a r y of the quest ionna i re content is p rov ided be low and the comple te tool is p rov ided in Append ix E . Infant Information: Birth date , gesta t iona l a g e , gender , birth weight , birth length, sibl ing number & a g e s Single R e s p o n s e Format: 1. L iquid feed ing prac t ices (6 quest ions) 2. Infant/toddler ce rea l feed ing prac t ices (12 quest ions) 3. Other so l id foods infant is eat ing (2 ques t ions) 4. Mo ther ' s current infant/toddler ce rea l pu rchas ing pract ices (7 quest ions) 5. Mo ther ' s percept ion of infant's a c c e p t a n c e of commerc ia l ce rea ls (8 ques t ions) 6. Information rece ived or obta ined by the mother about infant sol id food feed ing and her percept ions about the use fu lness of the informat ion (15 quest ions) Spreadsheet (multiple resp over time) Format: 1. T y p e s , b rands and quanti ty of l iquid infant rece ived over t ime 2. T y p e s , b rands and quanti ty of ce rea l infant rece ived over t ime 3. T y p e s , b rands and quanti ty of other so l id foods infant rece ived over t ime 34 DESIGN AND METHODS 3.3.3. Personal and Demographic Questionnaire T h e demograph i c quest ionna i re (19 quest ions) was adap ted f rom Innis et a l . (1993, 1994) and the Stat is t ics C a n a d a 1996 a n d 1991 C e n s u s . T h e quest ionna i re obta ined information on the mother 's a g e , marital s tatus, educa t ion , maternity leave and the fami ly househo ld s i ze , occupa t ions , i ncome , l anguages s p o k e n , ethnic backg round , food related pract ices, dayca re use , where the parents had b e e n born , and how long they had l ived in C a n a d a . T h e comple te quest ionnai re is p rov ided in A p p e n d i x F. 3.4. Interview Data Management and Analysis 3.4.1. Transcription from original data source E a c h interv iew w a s reco rded in full o n tape . T h e tape w a s then t ranscr ibed verba t im. A l l the transcr ipts we re then re -checked for a c c u r a c y by the researcher . T h e transcr ipt ion t ime var ied be tween 8 a n d 16 hours per tape. Transcr ip t ion t ime w a s determined by seve ra l factors; interview length, ski l l (that i nc reased with pract ice) , record ing qual i ty (background noise) , conversa t ion character is t ics (low tones , qu ick answers ) , and the deg ree of nonverba l t ranscr ipt ion (express ions) . 3.4.2. Data Analysis G r o u n d e d theory p rocedu res a re b a s e d o n two ana lys i s mode l s : the concept - ind ica tor mode l and the c a u s a l - c o n s e q u e n c e mode l (G laze r 1978; S t rauss and C o r b i n , 1990). T h e concept - ind ica tor ana l ys i s m o d e l d i rects the concep tua l cod ing of the identi f ied line c o d e indicators a n d l inks them with the evo lv ing c o n c e p t s . T h e constant c o m p a r i s o n of the mean ing of indicators to e a c h other s lowly bui lds a concep t a n d its propert ies to be labe led by the ana lys t (F igure 3 pg . 27) . T h e c a u s a l - c o n s e q u e n c e mode l d i rects the reassemb l ing of the da ta in new ways and is u s e d a s a f ramework to spec i fy the connec t ions be tween the ca tegor ies (Figure 4 pg . 28). T h e c a u s a l - c o n s e q u e n c e mode l of infant so l id food feed ing is i l lustrated in F igure 15 in the 35 DESIGN AND METHODS results. T h e s e 2 mode ls gu ided the deve lopmen t of 5 da ta m a n a g e m e n t s p r e a d s h e e t s for the data ana lys i s p r o c e s s a n d concurrent da ta m a n a g e m e n t p rocedures . T h e sp readshee t s a ided in the organ izat ion of and fami l iar izat ion with the text, and then with the th inking, interpretation, unders tand ing and integration of the evo lv ing concep ts and ca tegor ies . T o a id in t rack ing da ta throughout the ana lys i s p r o c e s s , line numbers were used on e a c h page of t ranscr ipt (348 pages) for the identi f icat ion of any c o d e d mater ia l s o that it cou ld be t raced back to the or iginal interview da ta s o u r c e for veri f icat ion. F igure 5 i l lustrates the organizat ion of the transcript da ta . Marg in s p a c e w a s used on the right s ide of e a c h page of the transcript to hand write line c o d e s (LC) of important words and s e n t e n c e s ( indicators) identif ied f rom the text. Interview Transcript with Line Codes in the right Margin Space Interview number (0001 )and Da te (7 months , Breas t - feed ing , M a l e , St . J a m e s C o m m u n i t y Cen te r ) 1 (line number 1) 2 3- start ing at 4 months w e g a v e 4- h im rice ce rea l but then w h e n 5- he didn't l ike that we sw i t ched 6- to M i l upa he never l iked P a b l u m 1000. . . v 2 0 0 0 (line number 2000) Line C o d e s (indicators) 3- starting (a process) 4- cereal type - rice 5- didn't like it (food rejection) 5- switching 6- cereal brands Figure 5. Transcr ip t organ izat ion a n d l ine cod ing (LC) p rocedures . Part ic ipant numbers and descr ip t ive da ta (e.g. , infant a g e and gender , milk feed ing method , recrui tment site) were written at the top of the page . P a g e line numbers were inserted on e a c h page to t rack da ta throughout the ana lys is p r o c e s s . Transcr ip t ion text w a s typed on half of the page . Marg in s p a c e on the right s ide of the p a g e w a s used to efficiently t ransfer indicator l ine c o d e s f rom the text to the margin s p a c e , for ana lys i s . 36 DESIGN AND METHODS The resulting line codes, as illustrated above, were transferred to an indicator index summary spreadsheet (MSS) (Figure 6). These spreadsheets were used as a quick reference of all line codes with the identifying line number from the original data source. The indicator index summary spreadsheets were used to aid in the first analysis procedure - open coding (Strauss and Corbin, 1990). The aim of this procedure was to systematically pull apart important words, sentences and paragraphs from the transcript in order to understand the data. A key analytic procedure used to enhance analytic sensitivity is to ask generative questions. The typical questions often asked are; who, where, what, how and why some behavior or event has happened. In this way, the constantly comparing of new 'indicators', allowed the properties and dimensions of important emerging concepts and categories to be discovered. The MSS spreadsheet aided in efficiently analyzing the large amount of data from the transcripts, systematically, both within and across the interviews. 37 DESIGN AND METHODS Indicator Index Summary Spreadsheet (IISS) Interview 0001 3- starting (a process) 4- cereal type - rice 5- didn't like i (food rejectic 5- switching 6-cereal bran 0 0 0 2 n) ds 0 0 0 3 0004 0005 0006 Indicator Index Summary Spreadsheet (IISS) Interview 0 0 0 7 0 0 0 8 0 0 0 9 0 0 1 0 0011 0012 Figure 6. Indicator Index S u m m a r y S p r e a d s h e e t (IISS) for l ine c o d e organizat ion. T h e line c o d e s f rom e a c h interview we re t ransferred into 2, 6 co lumn indicator index s u m m a r y s p r e a d s h e e t s (IISS). T h e interview n u m b e r w a s u s e d a s the head ing of e a c h co lumn . T h e original l ine number was a l so t ransferred to track the original s o u r c e of the da ta throughout the ana lys i s p r o c e s s . Cons tan t compara t i ve ana lys i s within and a c r o s s c a s e s w a s started us ing the o p e n cod ing p rocedures . A ref lexive journal w a s kept to documen t evo lv ing concep ts , ca tegor ies a n d their re lat ionships. T h i s journal b e c a m e the a v e n u e for evo lv ing theoret ical thinking about the da ta , inc luding c r o s s c o m p a r i s o n s a n d pre l iminary interpretat ions. T h e two data m a n a g e m e n t s p r e a d s h e e t s were used to record the ana lys t ' s thinking and we re labe led m e m o sp readshee t a and b ( M S a a n d M S b ) , respect ive ly . A n e x a m p l e of the first m e m o sp readshee t is prov ided in F igure 7. T h e s e c o n d m e m o sp readshee t ( M S b ) is desc r i bed in more detai l in F igure 9. 38 DESIGN AND METHODS Memo Spreadsheet (MSa) Concept/ Category (e.g. starting) Analysis Session Dates Starting.... A d ia logue of what, w h e n , who , why, and how mothers start sol id foods a n d the interpretat ions of what the feed ing p r o c e s s is l ike for t hese mothers . Diagram Example, Figure 7. T h e m e m o s p r e a d s h e e t ( M S a ) was u s e d for the organizat ion of ana lys t ' s theoret ical thinking dur ing the o p e n c o d i n g ana l ys i s p rocedures . T h e concep t or ca tegory w a s p laced a s a head ing a long with the date of the ana lys i s s e s s i o n . Ref lec t ive thinking o n the m e a n i n g s of the da ta was written a n d s u c c e s s i v e rev is ions were d o c u m e n t e d a s the ana l ys i s con t inued . Genera t i ve ques t ions (when, why, what , who , a n d how s o m e behav io r happened) we re a s k e d of the da ta to prov ide a f ramework to write f rom. D i a g r a m s a n d f igures w e r e inc luded in the journal to a id in integrat ive thinking about re lat ionships of concep ts or ca tegor ies to e a c h other, a n d to a id in mak ing expl ici t , u n c o n s c i o u s pe rsona l b i a s e s that m a y in f luence the ana l ys i s . T h e journal entry rev is ions ref lected increas ing ly soph is t i ca ted reconst ruc t ions of the prev ious vers ions . T h e major c o n c e p t s a n d ca tegor ies that evo lved in the o p e n cod ing p rocedure were used a s the gu id ing f ramework to ga ther s u b s e q u e n t da ta sys temat ica l l y f rom a c r o s s the interv iews. In order to m a n a g e this da ta , a third sp readshee t , the concep t /ca tegory s u m m a r y sp readshee t , w a s d e v e l o p e d (F igure 8). A l l of the da ta f rom within and a c r o s s the interviews that cou ld potential ly 'fit' into a spec i f i c concep t / ca tego ry we re t ransferred to the concep t / ca tegory s u m m a r y sp readshee t ( C C S S ) with the identi fying l ine number f rom the or ig inal transcript. T h e n , the or ig inal quote within its ful ler context w a s t ransferred, aga in inc lud ing the identi fying l ine number , to this s u m m a r y sp readshee t . B e c a u s e ana lys i s quality cou ld va ry f rom interview to interview 39 DESIGN AND METHODS due to analyst fatigue, each interview transcript was purposely sifted a final time for each identified category. In this way, each transcript was 'equally' searched and sorted for all of the data that could fit into the identified concept or category. The axial coding procedures were started from the data in this spreadsheet. Concept/Category Summary Spreadsheet (CCSS) i Mixing 0001 - all the potential data (including source) 0007 from interview number 1 on the concept mixing. 0002 0008 0003 0009 0004 0010 0005 0011 0 0 0 6 0012 -all the potential data (including source) from interview number 12 on the concept mixing. Figure 8. The Concept /Category Summary Spreadsheet (CCSS) was used for the organization of data for the main concepts and categories of this study. All data from each interview that could potentially fit into the major concept/category identified was transferred to the C C S S . The interview number and source of the data were included. An illustration of the concept 'mixing' is shown. 40 DESIGN AND METHODS A s would be e x p e c t e d , the interpretat ions recorded in the reflexive journal evo lved dur ing the ana lys i s p r o c e s s . T h e first analyt ic m e m o s ( M S a ) f o c u s e d on art iculat ing interpretat ions f rom the o p e n cod ing ana lys is p rocedu res . A s the ana lys is cont inued and p rog ressed to the ax ia l cod ing p rocedures the m e m o sp readshee t now ref lected the inc lus ion of the cond i t ions within a spec i f ic context and the c o n s e q u e n c e s of ac t ions and interact ions of the p h e n o m e n o n . T h e s e c o n d m e m o sp readshee t ( M S b ) w a s d e s i g n e d to capture the interpretat ions f rom the axia l cod ing p rocedures (F igure 9). Memo Spreadsheet (MSb) Concept/Category; Starting Interview # When Why What Why How (process) 0001 0002 0003 0004 0005 0006 ... 0012 Figure 9. T h e m e m o s p r e a d s h e e t ( M S b ) w a s u s e d for the organ izat ion of ana lys t ' s theoret ical thinking dur ing the ax ia l cod ing ana lys i s p rocedures . T h e concep t or ca tegory w a s p laced a s a head ing , i l lustrated in this f igure is 'start ing' , and the interview number w a s p laced o n the left c o l u m n . Da ta der ived f rom the generat ive ques t ions (e.g. , w h e n , why, what, who , a n d how s o m e behav io r happened) we re sys temat ica l l y sor ted into this f ramework . P laus ib le re lat ionships be tween concep ts or ca tego r ies were identif ied and documen ted a c r o s s all of the interv iews. T h e journal entr ies were rev ised numerous t imes and reflect improvements in the ana lys t ' s interpretat ions. 41 DESIGN AND METHODS Additional integrative da ta d isp lays were d e v e l o p e d to il lustrate the ana lys is of the concept /ca tegory s u m m a r y shee t da ta accord ing to the c a u s a l - c o n s e q u e n c e mode l (G laze r 1978 ; S t r a u s s & Co rb i n , 1990) and the resea rche r ' s interpretat ions. T h e integrative da ta d isp lays a l so evo lved to reflect a more soph is t i ca ted unders tand ing of the mothers ' sol id food feed ing prac t ices . T h e ax ia l cod ing p rocedures were u s e d to d i scove r ' p rocess ' f rom the da ta . T h e s e results are i l lustrated in F igure 15 of the c a u s a l - c o n s e q u e n c e mode l (adapted f rom G lase r ,1978 ) . T h e p roposed s ta tements of p laus ib le relat ionship (hypotheses) be tween the mother 's feed ing pract ices and the infant 's ce rea l consumpt ion patterns evo l ved , in part, f rom the sort ing of the infant 's so l id food transit ion g raphs into low, m e d i u m a n d h igh ce rea l consumpt ion g roups . 3.5. Questionnaire Analysis T h e infant feed ing pract ice quest ionna i re w a s comp le ted with 9 of the 12 mothers who part ic ipated in the study. T h e quest ionna i re da ta were u s e d to comp lemen t the interview da ta . Da ta f rom the ques t ionna i res w a s not u s e d to stat ist ical ly quanti fy r esponses b e c a u s e the s a m p l e w a s too sma l l , a n d this w a s not the in tended pu rpose . T h e quest ionna i re da ta were u s e d to comp lemen t port ions of interview da ta , s u c h a s in the c a s e of the transit ion g raphs (check ing responses to interview data) . T h e quest ionna i re da ta a ided in unders tand ing the different r e s p o n s e s and types of da ta that c a n be ob ta ined f rom us ing the 3 different formats (c lose r e s p o n s e ques t ions at o n e point in t ime, sp readshee t r e s p o n s e s over t ime, and interview responses ) . T h e pe rsona l a n d d e m o g r a p h i c ques t ionna i re w a s u s e d to prov ide demograph i c da ta on the character is t ics of the s tudy part ic ipant. 42 RESULTS Chapter IV 4.1. Participant characteristics A total of 12 w o m e n part ic ipated in this s tudy. Of the 12 w o m e n , 7 had infants who were be tween 6.5 a n d 7.5 months of a g e , 3 had infants who we re be tween 8 and 9 months and 2 had infants who were 9 months of a g e (Table 1). T w o thirds (9/12) of the infants were ma le . Half of the w o m e n had a g ross fami ly i ncome greater than $ 7 0 , 0 0 0 and 2 w o m e n had an annua l fami ly i ncome less than $20 ,000 . Of the 12 w o m e n , on ly one w o m a n had two ch i ldren. Mos t of the w o m e n were marr ied or l iving with a partner, 2 we re s ing le . Al l of the mothers and al l but 1 father had comp le ted pos t - seconda ry educa t ion . T w o thirds of the mothers and three quar ters of the fathers had comp le ted Univers i ty . T h e majority of mothers (9/12) were be tween 25 and 34 yea rs of age . L e s s than half of the mothers u s e d d a y c a r e . O f t hose w h o u s e d dayca re , 3 u s e d it part t ime and 2 full t ime. 43 RESULTS Table 1 Participant Characteristics Number1 Infant age (months) 6.5 - 7.5 >8-<9 9 Infant Gender male female Gross Family Income (x $1000) < 1 0 10-19 20-29 30-50 50-59 >70 Birth Order first second Marital Status Single Married/common-law Mother's education College University Father's education High School College University Mother's age (yrs) 20-24 25-29 30-34 35+ Alternate Infant Care Part time (1-2 d/wk) Full time (5d/wk 8hrs/d) 7 3 2 9 3 1 1 1 2 1 6 11 1 2 10 4 8 1 2 9 2 5 4 1 3 2 A total of 12 mothers participated. 44 RESULTS 4.2. Overview T h e interview da ta were a n a l y z e d us ing grounded- theory p rocedures to desc r i be the mothers ' so l id food feed ing p r o c e s s e s and to exp lore the p laus ib le relat ionship be tween infant so l id food feed ing pract ices a n d infant nutrit ion. Dur ing the constant compara t ive ana lys i s , f ive t h e m e s were d i scove red . T h e 5 t h e m e s - the feeding process, perceiving infant food needs, ways of feeding, gaining expertise and tailoring the transition process are desc r ibed in the fo l lowing sec t i ons . T h e last t heme - tailoring the transition process w a s identif ied a s the co re t heme b e c a u s e it accoun ts for the mos t var iat ion in the mothers ' behav iors within the context of the so l id food feed ing p r o c e s s . T h e 5 t h e m e s are i l lustrated in the fol lowing 3 -d imensional mode l (F ig . 10). T h e mode l p rov ides a v isua l presentat ion of the f indings. Th is conceptua l mode l a ids in refining p laus ib le re lat ionships a m o n g the t h e m e s and e n h a n c e s unders tand ing of the n u m e r o u s cond i t ions that potent ial ly in f luence the so l id f ood feed ing p r o c e s s . T h e ava i lab le d a t a c lear ly sugges t that the 'way" that the mother ' tai lors' her feed ing strategy dur ing the transi t ion p r o c e s s cou ld impact o n the infant 's a c c e p t a n c e of so l id f oods a n d thus, potential ly, the infant 's so l id food consumpt ion pat terns. 45 RESULTS Perceiving Infant Food Needs F o o d preferences (taste-texture) Hunger Ways of feeding Dynamic . switching . mixing . adjusting . engagi"9 etc. Static . repeatediy ottering dis- liked toods . waiting . distracting etc. ' Readiness . | Developmental y < f f 1 / / / / Figure 10. The 3-dimensional model links the 5 themes - the feeding process, perceiving infant food needs, ways of feeding, gaining expertise and tailoring the transition process of infant solid food feeding. The first theme, the feeding process includes 3 concepts (food acceptance/rejection, starting the feeding process and infant age). The second theme, perceiving infant food needs includes 3 concepts (the mother's perception of infant food taste and texture preferences, infant hunger and developmental readiness such as risk of allergies or choking). The third theme, ways of feeding identifies infant feeding strategies that appear to be dynamic or static in promoting solid food acceptance. The fourth theme, gaining expertise includes 5 concepts (finding and using resources, feeling scared, being a first time mother, seeking reassurance and learning through trial and error). The fifth theme and core category, tailoring the transition process, describes the key determinant influencing the outcome of the solid food feeding process. The theme 'tailoring the transition process' explains best the potential variations in solid food acceptance and consumption patterns described by the 12 mothers in this study. 46 R E S U L T S 4.3. The feeding process T h e first t heme - the feeding process, of the 3 - d imens iona l infant so l id food feed ing mode l is i l lustrated in F igu re 1 1 . T h e first t heme is compr i sed of 4 major c o n c e p t s - start ing the feed ing p r o c e s s , the infant 's a c c e p t a n c e or rejection r e s p o n s e , the infant 's a g e a n d the sol id food of fered. T h e mode l e m p h a s i z e s the connec t ion be tween the mother - infant pair a n d food a s the integral part of the d y n a m i c ( interactional) feed ing p r o c e s s . T h e mothers in this s tudy desc r i bed their expe r i ences feed ing their infants a s they p rog ressed f rom the exc lus ive l iquid diet to the c o m b i n e d l iquid and so l id f ood diet. T h e F e e d i n g P r o c e s s Infant Figure 11. T h e first t h e m e of the 3-d imens iona l infant so l id food feed ing m o d e l is the feeding process. T h e first t h e m e inc ludes 3 concep ts (food accep tance / re jec t ion , start ing the feed ing p r o c e s s and infant age) . 47 RESULTS T h e mothers desc r i bed 'start ing' the feed ing p r o c e s s and 'offering' their infants so l id foods . In turn, the infants ei ther a c c e p t e d or re jected what w a s of fered. T h e p rocess a p p e a r e d to be c i rcular in nature and thus, is highl ighted by the 2 a r rows in the mode l . T h e s e ar rows indicate different behav iora l pa thways , depend ing o n how the infant r esponded to the sol id food(s) be ing of fered. T h e s u b s e q u e n t t h e m e s in the s tudy that bui ld the concep tua l mode l are related to the context - the feeding process - a s ei ther condi t ions, act ion/ interact ional s t rategies, or c o n s e q u e n c e s . T h e mothers desc r i bed their expe r i ences of 'start ing' the feed ing p rocess and the factors that in f luenced their feed ing dec i s ions . 4.3.1 Starting the feeding process T h r e e mothers first in t roduced infant ce rea l s at 3 months , six mothers introduced c e r e a l s be tween 4 a n d 5 months a n d three mothers be tween 5 and 5 Vfe months . Mos t of the mothers (9/12) in t roduced so l id food to their infant within the r e c o m m e n d e d age range of 4 to 6 months . Interestingly, the mothers desc r i bed the mean ing of 'start ing the feed ing p rocess ' , however , the a g e of so l id food introduction prov ided on ly a v a g u e descr ip t ion of 'start ing'. T h e fol lowing mothers desc r i bed distinct 'start ing' patterns in their feed ing that they art iculated as "sporad ic " ve rsus "routine" feed ing. T h e a g e t hese mothers started so l id food feed ing was desc r ibed not a s the initial a g e of ' introduct ion' , but rather a s the a g e w h e n they were actual ly feeding sol id food on a regular bas i s or 'routinely*. Initial feed ing at tempts were not cons ide red a s 'real ly start ing' so l ids . T h e fol lowing quo tes i l lustrate the mother 's conceptua l iza t ion of initial feed ing at tempts a s be ing 'sporad ic ' and then the s u b s e q u e n t 'routine' feed ing of so l ids on a regular bas is . "We, I think we tried as early as 3 months... we tried [cerealf a couple nights [to get him to sleep at night] and then we stopped. Because we realized that it wasn't really making a difference and it was just more hassle than it was worth. I think we tried it. ..sporadically as he got a bit older, like after four months between 4 and 6 months but nothing really on a regular basis until 6 months... (7-147)"3. 2 Parentheses indicate added context to increase reading ease and understanding. 48 RESULTS "Started [cereal] at about right at about four months and he wasn't taking it too well so I sort of held off for another couple weeks so we really didn't probably start till he was about 4 1A> months. And then I started with the cereals first ...4 (10-87)". 'Start ing the feed ing p r o c e s s ' w a s desc r i bed by the fol lowing mother, aga in not as the age w h e n foods were initially in t roduced, but a s the age of 'routine' so l id food feed ing . Dur ing the fol lowing mother 's initial feed ing at tempts s h e desc r i bed both the irregular start - s top nature of ' feeding' so l ids , in relation to her percep t ions of her infant's food n e e d s (i.e., infant hunger) . T h e fo l lowing quo te a l s o i l lustrates the concep t of 'start ing' in severa l dist inct w a y s . F o r examp le , th is mother a p p e a r s to be start ing ' sporad ic ' initial f eed ing , start ing 'routine' feed ing and 'starting the feed ing p r o c e s s ' . Start ing the feed ing p r o c e s s , in this mother 's c a s e , a lso s e e m s to inc lude the mother 's p rogress ion to feed ing inc reas ing var iet ies of so l id foods , s u c h a s f rom cerea ls to vege tab les , a s wel l a s food co lor var iety, s u c h a s within the vege tab le food group. Th i s quote highl ights the t ime it took be tween the initial introduction of so l id foods to feed ing so l ids on a regular bas is ('routinely'). Wi th respect to iron nutrit ion, it is of interest that the mothers in this s tudy took f rom 2 w e e k s to over 3 months after the initial sol id food ' introduct ion' at tempts to start feed ing iron fortified infant ce rea l s o n a regular bas i s . "He's always slept at least 5 hours a night. And at six weeks he started sleeping 8 or 9 hours and then at 14 (weeks) he started waking up again so ummm we started giving him a little bit of... ah rice cereal.... he seemed to not need it after a little bit, so we stopped... so we've actually had to do that a few times... before we really started feeding him at ahh 4 ¥2 months we did it again...And then, let's see, when did we start, actually feeding and food. At roughly 6 months we started giving him...oatmeal, baby oatmeal and baby mixed cereal and then we started giving him squash very shortly after that and then we tried green beans and when he was used to that we would alternate... what we gave him, the green and the yellow (9-90-132)". T h e mothers in this s tudy, a s the quo tes il lustrate, desc r i be the infant 's a g e and the type of sol id food they of fered a s important factors within the context of the feed ing p r o c e s s . Numbers in parentheses indicate the participant interview and the page line number (e.g., 7 indicates the quote is from participant number 7 and 147 indicates that the quote is found on line number 147 in the interview transcript). 4 ... indicates either pauses in the mother's conversation or the joining of different quotes on the same topic. 49 RESULTS There fore , t hese 2 c o n c e p t s in the " feed ing p rocess " t heme are i l lustrated in the conceptua l mode l a s intertwined with 2 other concep ts : 'start ing/offering' and 'acceptance/ re jec t ion ' of so l id food(s). T h e prev ious , a s wel l a s the fo l lowing quotes , highlight the relat ionship be tween the infant's age , the sol id food of fered a n d the mother 's act ions - 'start ing' the feed ing p rocess . 4.3.2. Reasons for starting solid food In genera l , the mothers in this s tudy s ta ted that they had 'started' sol id food at the age they spec i f ied for one or more of three ma in r easons . T h e y usua l ly desc r ibed a combinat ion of reasons a s important in inf luencing their feed ing prac t ices . T h e three ma in reasons identif ied f rom the d a t a we re adv i ce (from read ing o r verbal ly) , pe rce i ved infant food n e e d s , a n d want ing the infant to s l eep through the night. T h e majori ty of mothers (10/12) s tated that they had started first foods at the age they spec i f ied b e c a u s e of the adv i ce they had obta ined either f rom reading or verbal ly. T h e majority of adv i ce ob ta ined by mothers a p p e a r e d to be spec i f i c to the a g e of introduction of so l id foods . "Introducing the solids has been based on what I have read and a bit of information that you do get which is 4 to 6 months, start on the cereals (6-124)". "Oh, I just figured at 4 months I'd try it, so that's what happened... I just, from reading books, you know, between 4 and 6 months they try cereal, so...I always tend to read ahead (2- 174)". M a n y mothers (7/12) a l s o s tar ted feed ing so l id f oods b e c a u s e of their percept ions that the infant behav io rs that they o b s e r v e d mean t their infant w a s ' ready 1 for, or their infant 'wanted ' so l id food . A s i l lustrated in the fo l lowing quote , the infant 's s i gns of ' read iness ' appea red to inf luence the mother 's s u b s e q u e n t so l id food feed ing dec i s i ons . W h e n the mothers obse rved infant ' s igns ' that they pe rce i ved a s the infant 'want ing ' so l id food they responded by start ing the feed ing p r o c e s s . 50 RESULTS "/ started right at 4 months because she was ready for it but she took it from a spoon no problem. You know she could sit you know propped up. She couldn't sit by herself, but she could sit propped up, she umm so she was ready. She's a strong big kid (5-689)". Deve lopmen ta l behav io rs (i.e., infant be ing ' interested') and phys ica l c u e s (i.e., infant sitting) a p p e a r to be 'tr igger' behav io rs that in f luenced mothers to start so l id foods . Mothers ' percept ion of infant ' read iness ' is d e s c r i b e d in more detai l in the next sec t ion on 'perce iv ing infant food n e e d s ' . T h e concep t 'fits' into both sec t i ons s ince , in this sec t ion , the mother 's percept ion of her infant 's ' r ead iness ' a p p e a r e d to in f luence the a g e that so l id foods w e r e in t roduced a n d in the next sec t ion , the mothers a p p e a r e d to pe rce i ve that the infant's ' read iness ' in f luenced their a c c e p t a n c e of so l id foods . C o n s e q u e n t l y , t hese percept ions a p p e a r e d to in f luence the mother 's feed ing dec i s i ons initially, w h e n 'start ing' the feed ing p r o c e s s , a s wel l a s at later s tages of the feed ing p r o c e s s . O n e quarter of the mothers (4/12) s ta ted that they had int roduced so l id foods at the a g e they d id b e c a u s e their infant w a s not s l eep ing through the night. Externa l factors, speci f ica l ly adv i ce f rom fami ly and pee rs s e e m e d to be very influential to these mothers ' feed ing dec i s ions . A s the fo l lowing quotes i l lustrate, the infant wak ing in the night appea rs to have been perce ived by t hese mothers a s a hunger c u e and a ' s ign ' of read iness to start so l ids . It is of interest that most (3/4) of the mothers w h o star ted so l ids b e c a u s e their infant w a s wak ing in the night a lso s ta ted that start ing so l ids w a s not s u c c e s s f u l in help ing their infant subsequen t l y s l eep through the night. T h e connec t ion be tween the mothers ' percept ions concern ing day t ime sol id food feed ing a n d uninterrupted night t ime s l e e p hours is c lear ly important b e c a u s e these percept ions a p p e a r e d to s t rongly in f luence so l id food feed ing dec i s ions (i.e., ' too' ear ly of introduction). "Everyone was saying once you start that then they will sleep through the night so that was my incentive to start it but truth be told she didn't sleep through the night. So I don't think it's food I think it's habit (5-76)". "Start, um like the Pablum. We actually tried it a little bit early, just the rice Pablum to see if he would sleep though the night with it... and that didn't work... We, I think we tried as early as 3 51 R E S U L T S months... (7-77). [The] doctor told us not to and we did it anyway (7-98)...Because my mothe --in- law said "it really does work", "everybody in the family has done if. So we tried it and it didn' make him sleep any more and he didn't seem to really take to it because he was still kind of spitting it out (7-100)". Mult iple external factors, s u c h a s adv i ce , compar ing with other mothers , rapid infant growth, b reas t - feed ing f requency a n d s leep ing through the night, a p p e a r e d to inf luence w h e r the fol lowing mother star ted feed ing so l id foods . T h e quote a l so highl ights the complex i ty of facti <rs that in f luenced this mother 's so l id food feed ing dec i s i ons . Interestingly, a l though this mother obse rved that her infant w a s growing very wel l on breast milk s h e c h o s e to introduce sol id fo< d s at 3 months ('too early"). T h e infant's posi t ive growth r e s p o n s e to the milk feed ing method di< I not a p p e a r to in f luence her feed ing dec i s i ons a s m u c h a s the other external factors, s u c h as her mother 's adv i ce a n d compar ing feed ing prac t ices with other mothers at work. "At three months because he was growing so fast he I started him on a regular Pablu n at night before he went to bed... which was my mother's idea. Because she was a public health nurse back in the sixties and that is what they did back then (8-34)".... Because we were brea st feeding every two to three hours he was only seven pounds twelve ounces when he was bon >. But he was I think twenty almost twenty pounds by the time he was four months. So he put o\ i a lot of weight very quickly. Ya and he didn't [sleep through the night]. But he really seemed to ike the Pablum...so I just kept doing it. He didn't start sleeping through the night until I had him completely weaned...at about 6-6 ¥2 months (8-311). Friends at work said... Their baby was sleeping. Part of the reason I started Pablum so early... I thought... [He's] got to be sleeping 0 I- 665)". 4.3.3. Reasons for solid food selection. T h e first so l id food that most mothers in t roduced (11/12) w a s commerc ia l iron-fortifie< I infant r ice c e r e a l . T h e on ly mother w h o didn' t in t roduce r ice ce rea l first in t roduced m ixed c e n sals ins tead b e c a u s e of a purchas ing error. T h e mothers in this s tudy a p p e a r e d to fol low the c u m snt infant feed ing recommenda t i ons , wi th regards to the type of so l id f ood they of fered their infan s first. T h e two mos t c o m m o n reasons the mothers in this s tudy stated for se lec t ing the sol id fc ods 52 RESULTS that they did w a s infant so l id food a c c e p t a n c e (12/12) and rejection (6/12) and concern about a l lerg ies (8/12). T h e infant's a c c e p t a n c e of the so l id foods offered c lear ly in f luenced the mother 's sol id food se lec t ion c h o i c e s . Further, half of the mothers ' food se lec t ion dec i s ions were speci f ica l ly de te rmined by the infants' reject ion of the so l id food of fered. T h e ar rows in the mode l highlight the c i rcu lar relat ionship be tween the mother - infant pair and sol id food . T h e ar rows in the mode l symbo l i ze the mother start ing the so l id food feed ing p rocess , the infant respond ing to what w a s of fered, the mother then respond ing to her infant's food c u e s and s o on - the circular p rocess . T h e quotes be low highlight the infant 's rejection response to the so l id food that w a s fed . A g a i n , the mothers appea r to be adapt ing 'what ' they fed their infants in r e s p o n s e to the infant's so l id food a c c e p t a n c e or rejection r e s p o n s e . F o r examp le , they either con t inued to feed what w a s a c c e p t e d , sw i tched foods or b rands , or m ixed foods together to promote a c c e p t a n c e . T h e feed ing s t rategies that the mothers u s e d to ga in so l id food a c c e p t a n c e are further deve loped later in the third t heme - ways of feed ing . Interestingly, the transcr ipts sugges t that both the mother and the infant in f luenced the p rog ress ion of so l id food a c c e p t a n c e (i.e., the sol id food feed ing p rocess ) . "So, we just kept offering it every couple of weeks (3-116). What we offered him first...because that's the safest thing to start with is rice. So I started with rice and I went on to oatmeal [commercial cereal] and then I went on to oat cereal and then I went on to barley cereal and he didn't like any of them (3-621)... I tried making some homemade food for him, so like mushed bananas or pureed carrots or applesauce and he didn't like any of that either... Earth's Best... He loves it...So that's what he eats (3-199)". "[I] was giving her the Milupa, and I... wasn't having any success with that at all so I started giving her the Gerber and some days she'd like it and some days she wouldn't. And now I have the Gerber with fruit and she just loves it (12-223)". "He didn't really like the rice cereals and then I, I think I switched to an oatmeal cereal for a brief time. Neither one did I finish the box and he didn't like it that much and now I use the Milupa mixed cereal and it's a lot more expensive but he likes it a lot better (10-87)". 53 RESULTS Cons is ten t with information prov ided in the publ ic health gu ide l ines, most of these mothers (8/12) a l so e x p r e s s e d an a w a r e n e s s of and /o r conce rn about a l lerg ies a s a major reason for introducing the first foods that they d id. T h u s , the information f rom the gu ide l ines appea rs to have in f luenced the mothers ' so l id f ood se lec t i on dec i s i ons a n d s u b s e q u e n t so l id food feed ing prac t ices . T h e fol lowing quote e m p h a s i z e s , in genera l , how strongly mothers adhere to the feed ing gu ide l ines with respect to a l lergy a w a r e n e s s , food se lec t ion and al lergy prevent ion. M a n y c o m m o n ph rases that mothers used that reflect guidel ine ' adhe rence ' include, " w e went with the l ist...that they r e c o m m e n d start ing with the least a l le rgen ic . . . l i ke what we ' re told and then went on to.. ." and "dur ing this t ime I w a s test ing for a l le rg ies" . T h e interview da ta c lear ly sugges t that mothers fol low gu ide l ines for direct ion regard ing the a g e to introduce speci f ic sol id foods and for the p rogress ion of inc reas ing the var iety of so l id foods in the diet, but they appea r to be fol lowing the gu ide l ines with a focus , in part icular, on a l lergy prevent ion. "He has been taking solid foods starting with just some rice cereal at 4 months he had no troubles, there has been no allergies or any difficulties with any of the food we've introduced... We went with the list of vegetables that they recommend starting with the least allergenic like squash, and sweet potatoes like what we're told and then went on to peas and beans and so on (4-50)." M o s t mothers we re c o n c e r n e d about the possib i l i ty of their infant hav ing a food al lergy. T h i s conce rn a p p e a r s to be a major determinant of not on ly what foods were fed first, but a l so how sol id foods were fed , with respect to inc reas ing variety, inc reas ing quantity, and the transit ion p a c e . T h e fo l lowing two quo tes desc r i be how the mother 's percept ion of ' testing for a l lerg ies ' cou ld impact on how qu ick ly so l id foods are in t roduced. "Started off with rice...he had gone through this episode with the Enfalac, umm, so I was, you know, I was a little concerned as to whether he was going to have any allergies...So I just, I was being cautious, as far as how quickly I introduced things (6-143)". "When she was getting to 6 months then she could have a bit more variety...like cause during this time I was testing for allergies so that's why you know you do one fruit... So at six months there was more variety and umm her meals were getting larger (5-246/263)". 54 R E S U L T S T h e fol lowing quote a l s o highl ights the mother 's conce rn about the possibi l i ty of her infant hav ing a food a l lergy and the impact that this conce rn had on w h e n s h e ' rout inely started sol id foods (i.e., at 6 months) . T h e quote i l lustrates potential con fus ion about food and a l lerg ies, s i nce this mother had started ' sporad ic ' so l id food feed ing by 3 months of age , in order to get her infant to s l eep through the night (quote not inc luded). T h e concep t start ing 'routine' feed ing ve rsus 'sporad ic ' introduction is important here s i nce the mother 's ear ly so l id food introduction a p p e a r e d to be pe rce i ved by her a s not putt ing her infant at risk for food a l lerg ies. A l though the mother c lear ly art iculated that her feed ing prac t ices were f o c u s e d a round a l lergy prevent ion and a p p e a r e d to fol low the gu ide l ines with respect to the type of foods s h e se lec ted , s h e did not a p p e a r to fol low the infant feed ing gu ide l ines , with respect to the a g e of introduction. " We didn't start him on solid foods until 6 months...because allergies run in the father's side... he didn't tolerate milk formula well or my breast-milk (7-39)... Started on the rice Pablum (7-77)... Once we started him on that, then we went on to yams because it was listed by the nutritionist, it was the least allergenic type of food (7-184)". T h e first t heme - the feed ing p r o c e s s desc r i bes the context sur round ing sol id food feed ing . T h e ava i lab le da ta s u g g e s t that the mothers interpreted 'start ing' the sol id food feed ing p r o c e s s a s 'routinely' feed ing so l id foods , and not necessa r i l y a s the a g e that so l id foods were first in t roduced. There fo re , it s e e m s poss ib le that there m a y be a prel iminary per iod prior to es tab l ish ing routine feed ing or food a c c e p t a n c e , w h e n the infant is be ing fed sol id foods 'sporad ica l ly ' . T h e concep t of ' sporad ic ' ve rsus 'routine' feed ing of so l id foods may or m a y not have nutrit ional impl icat ions, depend ing on the infant's total diet a n d a g e . Further, the mothers ' r easons for start ing sol id food at the a g e they c h o s e dif fered f rom the reasons for so l id food se lec t ion . T h e mothers were st rongly in f luenced to start feed ing their infant so l id foods by the fol lowing condi t ions - the adv i ce they had rece ived , the infant 's read iness and want ing the infant to s l eep through the night. In contrast , food se lec t ion dec i s i ons we re c lear ly in f luenced by the infant's a c c e p t a n c e or reject ion of the type of so l id food , or b rand , of fered and the mother 's 55 RESULTS concern about food allergies. The feeding process clearly appears to be influenced by many factors within the mother's proximate environment. 4.4. Perceiving infant food needs The second theme in the 3-dimensional infant solid food feeding model is perceiving infant food needs. The model (Figure 12) illustrates the link between the 2 themes - the feeding process and perceiving infant food needs. The second theme consists of 3 major concepts: the mother's perception of the infant's developmental readiness, the infant's food taste and texture preferences and the infant's hunger. The mothers observed and then responded to their infant's cues, the infant is ready, prefers a specific food, wants food or is hungry, or the infant is not ready, does not like a specific food, does not want food or is not hungry. Thus, the mothers' perceptions about the infants' food needs were related to the mothers' subsequent solid food feeding practices or how they moved forward or responded in their feeding decisions (starting and offering). Further, the mothers perceived that the major determinant of infant food acceptance was infant 'readiness', solid food preferences and hunger. The interview data suggest that the mothers' perceptions and the infants' food responses 'caused' the mothers' subsequent solid food feeding behaviors. 56 R E S U L T S The F e e d i n g P r o c e s s SOLID FOOD acceptance SOLID FOOD rejection Infant Ages 9 mo. • 6 mo, t 4 mo. STARTING/ thefprocess OFFERING solid food Perceiving Infant Food Needs F o o d Preferences (taste-texture) Hunger Readiness Developmental / / Figure 1 2 . T h e 3-dimensional infant so l id food feed ing mode l l inks the s e c o n d t heme 'perceiving infant food needs' with the p rev ious t h e m e 'the feeding process'. T h e s e c o n d t heme inc ludes 3 concep ts (the mother 's percep t ion of infant food taste and texture p re fe rences , infant hunger a n d deve lopmen ta l r ead iness s u c h a s risk of a l lerg ies or chok ing) . 4.4.1. Perceiving infant 'readiness'. T h e mother 's r e s p o n s e to her percept ion of her infant 's read iness c u e s (both phys ica l and cogni t ive cues ) w a s to 'start ' the sol id food feed ing p r o c e s s . T h e part icular infant ' read iness ' c u e s m a n y mothers o b s e r v e d w e r e : reach ing or trying to g rab , turning h is /her h e a d towards food , tak ing food f rom a s p o o n , sitt ing " p r o p p e d ' up, be ing interested in food , wa tch ing , fuss ing , be ing a "strong big k i d ' , growing fast , and wak ing in the night. T h e fo l lowing quote is an e x a m p l e of the 57 RESULTS interconnection between the cues the mother observed and her subsequent feeding response - 'starting' solid food. "At about 5 months old he was ah...I guess showing signs of wanting solid food cause we would be eating and he would be, you know, reaching out, or whatever, so umm so we started with the basics you know...Pablum (1-48) ...sitting with us and he'd be reaching for our food, and kinda... he was doing a lot (chewing on things) with his fist so you know... (-1-181)." The following 2 mothers' perceptions of their infant's solid food needs and their subsequent solid food feeding practices appeared to be influenced by their infant's growth patterns. The following quotes also illustrate how infant growth and possibly being physically large may be perceived by mothers as a sign of physical 'readiness' (i.e., cue) for starting solid foods. It is not clear from the available data if the quantity of food fed or the introduction age differs between physically large versus small infants. Although the rapid growth or the infant's size appeared to influence these mothers' solid food feeding practices it is not clear if their feeding practices were influenced by awareness of their infant's increased requirement for dietary iron during this rapid growth phase. "At 3 months because he was growing so fast he I started him on a regular Pablum at night before he went to bed. Waking more for additional feeds... that would be a big baby... (8- 35)". "I think he was just going through a growth spurt and he needed extra food (started rice cereal) and so we've actually had to do that a few times... (9-108)". The mothers also observed specific infant behaviors and perceived them as characteristic of the infant not wanting solid foods. The phrases the mothers used to describe these infant behaviors included turning down food, spitting it out, not opening his/her mouth, retching, clearly shutting his/her mouth, turning his/her head away, not being interested, "not taking if or "fighting if . The following quotes illustrate these mothers' perceptions. However, the first quote possibly illustrates an incorrect perception. It is not clear if the infant was not 'ready* for solids, if the infant just disliked the food offered, or if the mother was placing the spoon too far 58 R E S U L T S back in the infant 's mouth and thus c a u s i n g him to retch and spit the food up. T h e third quote i l lustrates how infant food refusal cou ld in f luence the feed ing d y n a m i c s , or v ise ve rsa , how feeding d y n a m i c s cou ld in f luence food a c c e p t a n c e . "[He] wouldn't have any Pablum (3-115)... I would just keep offering him you know rice cereal and he kept turning it down and spitting, you know, like not opening his mouth or just kind of like retching on what you put in his mouth and so I just thought, oh, well he's not ready for food (3-166)... He will always taste what you have to offer... If he does not like what you offer he will clearly (3-611) shut his mouth and turn his head (3-608). "Started, um, like the Pablum (o'kay). We actually tried it a little bit early... (7-77). He didn't seem to really take to it because he was still kind of spitting it out (7-104)". "From the beginning at 4 V2 months she just wouldn't feed. She would turn her mouth and she'd turn her head and she'd just fight it. And it was pretty much that way up until about a month ago (12-252)". S e v e r a l mothers pe rce i ved that their infant w a s show ing ' interest' in food (i.e., cogni t ive read iness c u e s ) . T h e concep t 'becoming interested was art iculated in the fol lowing two quo tes . . It s e e m s poss ib le that ' becom ing interested' in sol id food ( learning to accep t food) is a p r o c e s s over t ime that is in f luenced by the infant 's deve lopmenta l s tage , a g e and exposu re to food . T h e c i rcular a r rows within the mode l connec t ing the mother - infant interact ion a round food dur ing the feed ing p r o c e s s e m p h a s i z e that feed ing is a dynamic p r o c e s s . T h e mother 's percept ion of her infant ' becom ing interested' is poss ib l y a catalyst that ' t r iggers' her subsequen t feed ing dec i s i ons (starting/offering). Fur ther o n in the resul ts this concep t is p resen ted aga in with the feed ing strategy 'wait ing' b e c a u s e both c o n c e p t s a re re lated. T h e mothers a p p e a r to be 'wait ing' for the infant to respond or b e c o m e interested in the food that they are be ing of fered. "/ started when she was probably about 4 ¥2 months but she was not interested at all. She didn't actually become interested until about... probably about four weeks ago. At six months (12-239)". 59 RESULTS "He's really interested in our food now and so once they show an interest and [you] start giving them a little bit. Let them try it (10-599). [I] started right at ~4 months... wasn't taking it too well held off [for a] couple of weeks (10-87)". T h e ava i lab le da ta sugges t that there m a y be d i f ferences in feed ing pract ices that a re de te rm ined by the mother 's n e e d s rather than the infant 's f ood c u e s . Interestingly, seve ra l mothers ' so l id food feed ing p rac t i ces a p p e a r e d to be in f luenced by the mother herself 'want ing to feed ' so l id foods . T h e mother 'want ing ' or her ' read iness ' to feed so l ids cou ld be cons ide red 'mothers ' read iness ' . It is not k n o w n f rom the ava i lab le d a t a what the c o n s e q u e n c e s m a y be for an infant ve rsus a mother dr iven feed ing p r o c e s s . T h e fol lowing quote i l lustrates how this mother 's percept ions about ce rea l feed ing in f luenced her initial feed ing pract ices in a negat ive way . A s wel l , the quote e m p h a s i z e s the h igh leve l of conce rn the mother expe r i enced w h e n her infant re fused ce rea l . It s e e m s poss ib le that mothers ' percept ions are not on ly de termined by observa t ion of infant behav io rs at spec i f i c a g e s , but a l so by other factors related to food and feed ing within the feed ing context (i.e., pe r sona l factors) . F o r examp le , the mother be low desc r i bes her initial feed ing behav io rs of forc ing the infant to eat P a b l u m that he appea red to d is l ike, ins tead of the toast he a p p e a r e d to l ike. "Pablum which he never seemed to really like but I kept trying to stuff in his mouth, thinking I had to do this (1-48). Just recently I guess we just I just go more liberal with stuff and just I said well why am I forcing him to eat this when look he is reaching for my toast right now actually he wants to taste that toast you know, so let him try it, that kind of thing (1-98)". A further e x a m p l e of mother 'want ing ' or ' r ead iness ' to feed so l ids and progress in the feed ing transit ion p r o c e s s is i l lustrated by the fo l lowing quote. In this c a s e , the mother 's percept ions about her context (i.e., the work load of a s e c o n d ch i ld , go ing back to work) a p p e a r e d to have in f luenced her so l id food feed ing dec i s i ons and her p rac t ices . T h e mother desc r i bes the impact of hav ing to return to work on 'the feed ing p r o c e s s ' . H e r u s e of the p h r a s e " we started becoming", i l lustrates that a l though the infant m a y be ' ready 1 to start so l id foods the mother m a y 60 RESULTS a lso be 'want ing ' to feed so l id foods . T h e dua l mean ing of 'want ing/ read iness ' highlights the interact ional aspec t of sol id food feed ing (mother - infant - food). "/ started at work... so that I could know that he would be fine when I was away we needed to have him be eating solids... Umm, and that's sort of when (sitter) started watching him, that's sort of when we really started becoming... that's when I went and bought the food for him, you know, when I was leaving him for a full day but not just 4 hours or whatever... and I knew he was gonna to sort of be in a hard spot if he didn't have some food when I was away (3-513). To be brutally honest, with two children you know, you sort of look forward to slowing down on the feeding process (breast-feeding) (3-361)". Al though m a n y mothers pe rce i ved their infants were ready for sol id foods b a s e d on the behav io rs they o b s e r v e d , they s e e m e d to b e p u z z l e d or c o n c e r n e d w h e n the infant d id not accep t the sol id food that they of fered. S o m e mothers ' so l id food feed ing expe r iences c lear ly did not p rog ress a s they had expec ted b e c a u s e the infant re fused the food . T h e first quote i l lustrates the mother 's recogni t ion of infant deve lopmen ta l r ead iness c u e s . Howeve r , there s e e m s to be less recogni t ion of her infant 's food pre fe rence c u e s . T h e s e c o n d quote i l lustrates a mother 's frustration at her infant 's food r esponse . S h e desc r i bes her feel ings in compar i son to her expecta t ions a n d her percept ion of her f r iend's infant 's posit ive response to the sol id foods he w a s be ing fed . T h e s e mothers c o m p a r e d their infant with other infants that they knew. T h e y remarked on the d i f ferences be tween their infants. T h e interview da ta sugges t that mothers have expecta t ions about the feed ing p r o c e s s and that t hese expecta t ions m a y have been in f luenced by the c o m p a r i s o n s that they m a k e a m o n g their pee rs . "We waited for the same signs type of signs [as their first baby]... like you know, reaching for the food, watching you put the food in the mouth, trying to grab...you know just real a lot of attention around the food. I guess the other one was sitting up. You wait for them to sit up strongly before you offer food to them. I wouldn't have introduced him to food unless I felt he was physically ready or interested and he did appear interested. So I was surprised when he wasn't interested in what I was offering. I just thought, oh, o'kay, I am wrong, you are not ready. I talked to my doctor about it because I said, you know... he keeps turning down this food, and you know, 61 RESULTS what's going on. Because I have done it for, I consistently would offer it every couple of days for about a month or more and sort of you now, like, I was just a bit surprised... (3-1007-1033)". "Difficulties just his .. his not ummm accepting the food the way I though it should be...so sort of a frustration or whatever like I never, or just seeing my friend's baby eat like yum yum yum like he is in heaven you know then [my baby] kinda like Waaaaaahhhh his head going back and forth get this out of my face you know... and I'm worried he's not getting enough. ..(1-1960)". T h e mothers in this s tudy o b s e r v e d what they pe rce i ved as infant ' read iness ' c u e s . T h e c u e s they o b s e r v e d a p p e a r e d to inf luence their s u b s e q u e n t so l id food feeding pract ices, s u c h a s 'starting' so l id foods . T h e mothers ' ' read iness ' to feed so l id food or start the transit ion p r o c e s s a p p e a r e d to a l s o b e a n important determinant of so l id f ood feed ing dec is ions . It is not c lea r f r om the ava i lab le da ta if the infant 's a c c e p t a n c e of so l id food differs be tween a mother v e r s u s an infant dr iven feed ing p r o c e s s . Further, a l though m a n y mothers identif ied infant c u e s that they perce ived a s the infant ei ther be ing 'ready" or not ' ready 1 for so l id foods , the di f ference be tween food refusal c u e s (food pre ferences) a n d ' read iness ' c u e s (not ready for sol ids) a p p e a r e d to be more difficult for the mothers to d is t inguish. T h e mother 's abil i ty to recogn ize food ' r ead iness ' c u e s correct ly is c lear ly cr i t ical , s i n c e sol id food feed ing prac t ices (i.e. introduction age) a p p e a r e d to be in f luenced by infant food c u e s . 4.4.2. Perceiving infant food 'preferences'. Al l of the mothers in this s tudy d i s c u s s e d their observa t ions of their infant's food taste and texture p re fe rences , wh ich they perce ived a s a major determinant of their infant's a c c e p t a n c e of sol id food . T h e p h r a s e s u s e d to c o n v e y their percep t ions inc luded, "anyth ing swee t [he l ikes]" , "doesn ' t like the tas te" , " too tart", " a s t ronger taste a n d he l iked t h a f , " it had a lot of f lavor [meat] ' , "metal l ic k ind of taste [meat in j a rs j ' , " s o that s h e is happ ie r tak ing it [cereal] w e try putting s o m e f lavor into it for he r " , " b land ' a n d " rice [cereal] w a s too bor ing" . T h e fol lowing quotes il lustrate the p laus ib le relat ionship be tween the mother 's percept ion of her infant's taste p re fe rences , her feed ing strategy a n d the f inal c o n s e q u e n c e - ce rea l a c c e p t a n c e . T h e mothers c lear ly a p p e a r e d 62 RESULTS to have been 'tai loring' their feed ing s t ra teg ies ove r t ime accord ing to their food related percept ions . "Never liked [Pablum]... (1-54). So he eats it much better now because I will mix it with I make it a lot the consistency is a lot thicker and I think in the beginning it is so watery it.. Just so you know he didn't like it (1-140)... So then, we rice was too boring, ...so we went on to the oat the oatmeal and mixed it with applesauce and she took to that because it was sweet (1-386)". "7:30 she gets umm a cereal breakfast. And umm mixed with formula because she likes the taste better that way... this morning I tried mixing it with yogurt too. Just cause she doesn't seem to particularly like the cereals so.. .so that she is happier taking it, we try putting some flavor into it for her (11-161)". T h e mothers a l so u s e d numerous p h r a s e s to c o n v e y observa t ions a n d percept ions about food texture pre ference. T h e mothers used p h r a s e s s u c h a s ; " the cons i s tency is a lot th icker [cereal ] " , " watery 1 ' , " r u n n y , "doesn ' t l ike the c h u n k y s t u f f - t h e feel [prepared foods ] " , "s t r ingy, " t a c k y , " g r a i n y , " p u l p y , " [he's] not into hunks of any th ing " , " l ikes stuff fairly s m o o t h " , " t o o l u m p y a n d " he really wan ted someth ing a little bit smoother " . T h e mothers e x p r e s s e d two distinct i deas within the ' texture p re fe rences ' concep t . Tex tu re w a s either e x p r e s s e d by mothers accord ing to sol id food types (i.e., d i f ferences be tween c e r e a l s and meats) or a s a componen t of infant deve lopmen t (i.e., the infant 's p rogress ion f rom o n e cons i s tency to another , s u c h a s f rom 'wa te ry to 'thicker" ce rea l or pu reed to m a s h e d fruits and vege tab les ) . T h e fo l lowing two quotes e m p h a s i z e the impor tance of food textures to infant 's p re fe rences . T h e infant's accep tance of the sol id food of fered s e e m s to be dependen t o n the texture and f lavor of the food . T h e mother 's feed ing s t rategies (i.e. mixing) a p p e a r e d to be de te rmined by her percept ions of what textures her infant l iked a n d a c c e p t e d . Interestingly, the first quote a l so sugges ts that the infant's p rogress ion in food texture m a y b e food spec i f i c (i.e., v iscos i ty , f rom runny a n d s m o o t h to th icker a n d lumpier foods) . T h u s , p rogress ion dur ing the feed ing p r o c e s s f rom pureed to lumpy foods m a y differ depend ing o n the indiv idual food f ed (cerea ls , fruits, vege tab les and meats ) , b e c a u s e e a c h food has un ique texture character is t ics . 63 RESULTS "And then I guess just... 3 weeks ago I started chicken and beef (7 months)... I made it myself. Home made. Mashed or pureed it up and I really have to mix it. I would almost say like ...a ratio of one to four with vegetables. For him to eat it otherwise the consistency is too ummm, too strong, or not too strong but too umm, thick like, pulpy kind of deal. He likes his stuff really pureed even now. He's not into hunks of anything (6-197)... He still likes stuff fairly smooth, although, like his cereal we have it a lot thicker now, but veggies and stuff like that he seems to like umm fairly pureed... Consistency.. .new for him [meats]... More difficulty with the texture (6- 221-299) "She didn't like them because they have a sort of metallic kind of taste... those little jars [commercially prepared meats]...the meat it's umm...it's very tacky...it's grainy. I have to hide it in like a lot of vegetables or something...She bouck's on it. ...So I buy her a combination or I make my own (5-483 -518)". T h e fol lowing quotes il lustrate h o w the mothers ' food percept ions in f luence the 'way ' the infant is fed . T h e s e mothers are us ing the feed ing st rategy 'mix ing ' in r e s p o n s e to the infant's refusal of so l id food . T h e food p re fe rences be tween the two infants, for w h o m the fo l lowing quotes refer, differ. T h e first quote desc r i bes an infant w h o dis l iked ce rea ls , w h e r e a s the s e c o n d quote d e s c r i b e s an infant that d is l iked a p p l e s a u c e , yet both mothers used the ce rea l fruit mix ing strategy in o rder to p romote the d is l i ked f ood ' s a c c e p t a n c e . It s e e m s poss ib le that the infant 's food p re fe rences , s u c h a s a dis l ike of s o m e iron-fortif ied ce rea l s , m a y have negat ive c o n s e q u e n c e s for the amount of food c o n s u m e d . T h e mothers ' feeding strategy, with regards to promot ing so l id food a c c e p t a n c e a p p e a r s to be c lear ly important. "He takes [oatmeal/rice] doesn't like the taste of it so we do have to mix it with fruit to camouflage it (4-68)". "Usually now I just give him mixed with fruit because he doesn't always like fruit and I usually put applesauce in the cereal (2-215)... Because he won't eat it by itself, not usually, the applesauce. I think he just finds it too tart, a lot of fruits (2-22)... Carrots, broccoli, sweet potato, cauliflower, yams. He didn't like potato, but I haven't tried that in a long time anyway. And he tried turnips. It had a stronger taste and he liked that (2-299)". 64 RESULTS T h e mothers ' percept ions of their infants' food taste and texture p re fe rences appea red to be a key determinant inf luencing their so l id food feed ing strategies. Consequen t l y , s i nce the data sugges t that the mothers ' percept ions of infant food n e e d s we re related to feed ing dec i s i ons it s e e m s poss ib le that the mothers ' feed ing st rategy m a y impact (promote or dec rease ) the level of sol id foods the infant c o n s u m e s . 4.4.3. Perceiving infant 'hunger'. M a n y (8/12) of the mothers pe rce i ved that hunger in f luenced their infant 's a c c e p t a n c e of sol id food. T h e fo l lowing mothers fed ce rea l in the morn ing to their 'hungry" infants, before they f ed a bottle of fo rmu la a n d d e s c r i b e d h o w wel l the infant a te the ce rea l in the morn ing. T h e mothers used ph rases s u c h a s "t iming is every th ing" , "if s h e ' s hungry s h e ea ts very wel l , s h e eats lots, s h e eats very coope ra t i ve l y and " s o m e t i m e s s h e ' s just not in terested ' to desc r i be their exper iences . T h e ava i lab le da ta sugges t that s o m e mothers are aware of the connec t ion be tween the length of t ime be tween feed ings , hunger a n d the subsequen t a c c e p t a n c e of so l id foods . "So I don't give her another [bottle] one in the morning. So at breakfast time she's ...ya she's hungry, she's hungry at breakfast so that's she has the cereal then and she really likes it (5- 429)". [If I give] cereal before I give a bottle.. .[she] doesn't eat much cereal.. .[so] I don't give a bottle... [I] wait for an hour (11-192)... I think it's just its all timing, how hungry she is, how active has she been. 11-343... Could shovel it in, I mean you're amazed at how quickly she's consuming this you couldn't eat it this fast... Gobbling (11-391)... Sometimes she's just not interested. And I think it is more a matter umm just because it is lunchtime doesn't mean I'm hungry. Because with babies timing is everything... (11-481)... If she's hungry she eats very well, she eats lots, she eats very cooperatively and ahh that's been the best part I mean sometimes it's like I said she can eat it more quickly than you or I could I'm sure (11-495)". S o m e mothers s e e m to adjust the t ime be tween mea l s in response to their percept ions about their infant 's hunger, w h e r e a s other mothers a p p e a r to find the m a n a g e m e n t of ' feeding' 65 RESULTS cha l leng ing . T h e first quote desc r i bes a ' f lexible' so l id food feeding style where the mother appea rs to feed so l ids in r esponse to her infant 's deg ree of hunger. T h e mother in the s e c o n d quote a p p e a r s to be hav ing s o m e difficulty try ing to 'coord inate ' the t iming be tween the l iquid a n d sol id foods in the diet. T h e s e quotes reflect the d i f ferences between the mothers ' feed ing st rategies, e v e n though their percept ions about infant hunger were simi lar. T h e s e mothers appea red to be awa re of the impor tance of the t iming be tween mea ls and the infant 's deg ree of hunger. Further, they s e e m e d to be a w a r e of the impor tance of the infant 's deg ree of hunger to subsequen t f ood a c c e p t a n c e . "We feed him when he is hungry. Like dinnertime can be anywhere from 4:00 till 7:00 depending on...on when he's hungry (9-760)". "Milk, enough to be content...can't feed solids... Voracious appetite (7-724)... Itdepends how he is in the morning because usually umm, he wakes up happy and I give him a bit of milk... formula or some...solid food. But then sometimes he will just wake up screaming ... for food he is just so hungry and umm, like, I find it hard...I find he has gotten to the stage now where I can't he doesn't want to sit still (7-494)... Gets hungry... too upset...bottle quick... (7-880)... When I can get him in a good mood or, you know, try to coordinate it so that he hasn't just had a bottle,., you know, so that we've got enough space and time kind of between bottles that where he is hungry. You know there are times where he'll just like, eat, eat, eat (7-662)". Learn ing to identify the infant 's food c u e s appea red to be an important and ongo ing task for mothers dur ing the feed ing p r o c e s s . T h e fo l lowing quote highl ights this aspec t of sol id food feed ing . T h e mother is c lear ly ' f iguring out' or d is t inguish ing be tween the va r ious food c u e s in order to unders tand her infant 's refusal of food . T h e ava i lab le da ta sugges t that the mothers m o v e through 2 s teps w h e n 'perce iv ing their infant 's food needs ' . T h e first s tep involved gain ing an a w a r e n e s s of the ' s igns ' that infants m a y d isp lay dur ing the feed ing p r o c e s s . Th i s appea red to be n e c e s s a r y for the mothers in order to start a s wel l a s to m a k e dec i s ions throughout the feed ing p r o c e s s (e.g. , in terested, sitt ing up, reach ing a n d tak ing food f rom a s p o o n were ' s igns ' mothers assoc ia ted with so l id food feed ing ' read iness ' ) . T h e s e c o n d s tep cons i s ted of observ ing and recogn iz ing the food c u e s a n d then d is t ingu ish ing be tween them ( read iness , food taste and 66 RESULTS texture p re fe rences , and hunger) . In order for the mothers to respond appropr iately in their subsequen t feed ing st rategies they c lear ly n e e d e d to unders tand their infant's food c u e s . T h e fol lowing quote desc r i bes a mother learn ing to unders tand her infant's food c u e s (not hungry or d is l iked what w a s offered). In order for this mother to promote sol id food accep tance s h e c lear ly needs to be ab le to d is t inguish be tween the var ious food c u e s that s h e is observ ing . " / want to try and figure out if... is he hungry, oris he... is he not hungry or is he just doesn't like the food you know at the time. Whether he is you know he is turning his head is he turning his head because he doesn't like it or is he turning it because he is full... Sometimes like he would be hungry he just wasn't... he didn't like what we're feeding him (10-827)". T h e infant 's food c u e s are the essen t ia l link to unders tanding their unique food requests . Desp i te this impor tance , the reality is that the mother must interpret t h e s e intricate a n d often m ixed , food c u e s , within the infant 's chang ing env i ronment . T h e data sugges t that there m a y be a 'p laus ib le ' re lat ionship be tween the mothers ' percept ions of her infants' food needs and her subsequen t so l id food feed ing s t ra teg ies. Howeve r , appropr ia te feed ing r e s p o n s e s a p p e a r e d to be highly in f luenced by if or to what d e g r e e the mother unders tood her infant's food c u e s . 4.5. Ways of feeding. T h e third t h e m e in the 3 -d imens iona l infant so l id food feed ing mode l is i l lustrated in F igure 13. T h e mode l l inks the 3 t h e m e s - the feeding process and perceiving infant food needs, to the third t h e m e - i vays of feeding. Wi th in the context of the sol id food feed ing p r o c e s s , how the mother f e e d s her infant so l id foods a p p e a r s to be cont ingent on the feed ing strategy and/or technique(s) that s h e u s e s dur ing this p r o c e s s . T h u s , the third t heme identif ies the mothers ' sol id food feed ing p rocedu res . Further, the 'way 5 the mother f eeds her infant so l id foods appea rs to be s h a p e d , in part, by her percept ions of her infant 's food n e e d s a s wel l a s the infant's sol id food a c c e p t a n c e or reject ion r e s p o n s e s . T h e s e re lat ionships are i l lustrated in the 3 -d imens iona l mode l . T h e mother 's level of exper t ise or feed ing 'capabi l i ty ' a l so a p p e a r e d to have in f luenced 67 RESULTS the 'way 1 the infant w a s fed . T h e relat ionship of the fourth t heme , 'gain ing exper t ise ' , to the other t h e m e s is desc r i bed in the next sec t ion . T h e range of so l id food feed ing s t ra teg ies / techn iques that the mothers used we re identif ied a n d desc r i bed . Four teen feed ing techn iques we re identif ied and labe led a s ; offering, waiting, switching, mixing, adjusting feeding management, socializing, modeling or mimicking eating, engaging, playing, positioning (including restraining), distracting/sneaking or camouflaging, prying/stuffing/ forcing, pushing and holding back food . T h e feed ing s t ra teg ies / techn iques d e s c r i b e the range of p rocedures the mothers in this s tudy u s e d to f e e d sol id foods to their infants and potential ly reflect the sol id food feed ing ski l ls , incl ination and c o m p e t e n c e (sol id food feed ing capabi l i ty) of the mother. Further, the ava i lab le da ta sugges t that m a n y of the mothers w e r e 'adapt ing ' their feed ing s t ra teg ies / techn iques ove r t ime. T h e concep t 'adapt ing ' reflects the interact ion a round infant feed ing (mother - infant - food). T h e mother 's infant feed ing ac t ions (or react ions) a p p e a r to be in r e s p o n s e to spec i f ic contextual factors (the mother ' s percept ions of infant f o o d n e e d s , the infant 's r e s p o n s e to the sol id foods fed , the a g e of the infant, the level of feed ing exper t ise and the env i ronment) . T h u s , the mother a p p e a r s to have been ' tai loring' her feed ing s t ra teg ies / techn iques by 'adapt ing ' the 'way 1 s h e fed her infant dur ing the t ransi t ion p r o c e s s . C o n s e q u e n t l y , the concep t 'adapt ing ' c a n be further desc r i bed a long a d imens ion s i n c e the mother m a y or m a y not dec ide to adapt the w a y s h e feeds her infant in r e s p o n s e to the un ique contextua l factors of her current s i tuat ion. Interestingly, spec i f ic so l id food feed ing s t ra teg ies / techn iques a p p e a r e d to in f luence the a c c e p t a n c e of so l id f oods differently. 68 R E S U L T S T h e F e e d i n g P r o c e s s SOLID FOOD acceptance SOLID FOOD rejection Infant Ages 9 mo. 6 mo. 4 mo. STARTING/ thefprocess OFFERING solid food Perceiving Infant Food Needs F o o d Preferences (taste-texture) Hunger Ways of Feeding Dynamic . s«\tchin9 . mixing . adjusting . engaging etc. Static repeatedly ottering liked toods . waiting . distracting etc. Readiness Developmental y / / / / / Figure 13. T h e 3 -d imens iona l infant so l id food feed ing mode l that l inks the third t heme , ways of feeding with the prev ious two t h e m e s , the feeding process a n d perceiving infant food needs. T h e third t heme identif ies infant f eed ing s t rategies that appea r to be d y n a m i c or stat ic in promot ing sol id food a c c e p t a n c e . 69 RESULTS 4.5.1. Ways of feeding; 'Offering' and 'Waiting'. T w o mothers art iculated one 'way ' of feed ing that w a s labeled a s 'offer ing'. T h e term offering, in the context of the feed ing p r o c e s s , ref lects the mother 's behav ior of repeated ly offering prev ious ly re jected food to the infant. T h e infants of both of the mothers us ing this feed ing strategy did not a p p e a r to accep t c e r e a l s for a month and a half or longer. T h e transit ion g raphs (Append ix G ) sugges t that the infants we re accep t ing on ly very low leve ls of ce rea l dur ing the t ime w h e n t h e s e mothers we re repeated ly 'offer ing' the prev ious ly re jected c e r e a l s to their infants. T h e 'offer ing' s t ra tegy/ technique is i l lustrated in the fol lowing quote. It s e e m s poss ib le that repeated ly offer ing s o m e infants prev ious ly re jected foods does not lead to its a c c e p t a n c e . It is a l so poss ib le that the mothers ' behav ior of repeated ly 'offering' sol id foods ref lects an infant deve lopment s tage w h e n the infant m a y be ' test ing' the food . Th i s s tage m a y o c c u r prior to the infant's actual a c c e p t a n c e of the food . If this w a s the c a s e , the quantity of so l id food c o n s u m e d by the infant dur ing the ' test ing and offering' s tage wou ld be 'appropriately ' low for the s tage . T h e fol lowing quote w a s u s e d prev ious ly to il lustrate the infant 's lack of sol id food a c c e p t a n c e . He re , the pu rpose of reus ing this quote is to e m p h a s i z e the mother 's feeding techn ique - repeated offering and the c o n s e q u e n c e of the strategy that w a s u s e d . In the c a s e of food re fusa l , repeatedly offer ing the s a m e sol id foods to the infant m a y be reflective of the mother not 'adapt ing ' o r tai lor ing her feed ing st rategy to the infant 's food r e s p o n s e c u e s . "Wouldn't have any Pablum (3-115)... I would just keep offering him you know rice cereal and he kept turning it down and spitting, you know, like not opening his mouth or just kind of like retching on what you put in his mouth and so I just thought, oh, well he's not ready for food (3- 166").... I wouldn't have introduced him to food unless I felt he was physically ready or interested and he did appear interested. So I was surprised when he wasn't interested in what I was offering. I just thought, oh, o'kay, I am wrong, you are not ready... I consistently would offer it every couple of days for about a month or more and sort of you know, like, I was just a bit surprised... (3-1033)". T h e s e c o n d feed ing techn ique, labe led a s 'wai t ing' w a s desc r ibed by the fo l lowing mother. Th i s techn ique , a s the label sugges t s , m e a n s the mother is 'wait ing' for the infant to 70 RESULTS accep t spec i f ic so l id foods . T h e quote sugges ts that the mother m a y have been 'wait ing' for the infant to ' b e c o m e interested' in the infant ce rea l that w a s be ing of fered. Further, the mother s e e m s to have been wait ing for the infant to accep t the ce rea l wil l ingly. ' B e c o m i n g interested' is a 'cognit ive read iness ' c u e that w a s d i s c u s s e d in the prev ious sec t ion . T h e mother appea rs to be 'adapt ing ' her feed ing st rategy in r e s p o n s e to her percept ions of her infant's food needs . At first s h e states that s h e wou ld 'g ive in' a n d breas t - feed her infant w h e n he w a s not accep t ing e n o u g h ce rea l and w a s cry ing. S h e then learns to adapt her st rategy a n d d o e s not 'g ive in' and feed l iquids instead of the c e r e a l . T h e mother s e e m s to perce ive that her infant unders tands that he won' t be breast fed in p l a c e of be ing f ed so l id f ood . It s e e m s poss ib le that the 'wait ing' techn ique m a y be a key pre l iminary s tep in the p r o c e s s of the mother learning how to feed her infant so l id food . In another quote , this s a m e mother later u s e s the 'mix ing ' techn ique to inc rease food a c c e p t a n c e . T h e s e mothers s e e m s to be ' tai loring' their feed ing strategy by adapt ing the ' w a y they feed their infant in r e s p o n s e to the infant 's food c u e s . "Difficulties just his his not ummm accepting the food the way I thought it should be...so sort of a frustration or whatever like I never, or just seeing my friends baby eat like yum yum yum like he is in heaven you know then (my baby) kinda like Waaaaaaaahhhh his head going back and forth get this out of my face you know ..and I'm worried he's not getting enough.. .ya so that was definitely a difficulty just making sure he is getting enough and I would often give in and breast feed him you see (1-1960). ..So now we've reached that point where ...he knows that this is his feed and I'm not going to breast-feed him you know what I mean I used to give in so if he only had two bites of cereal and he is crying and wailing I would take him out of the high chair and rush over and sit down and feed him breast-feed him so he'd know what was coming see but now I don't do that and he is at that point where I think he is eating enough... (1-2000)". 4.5.2. Ways of feeding; 'Switching' and 'Mixing'. 'Swi tch ing ' types a n d b rands of ce rea ls a n d 'mix ing ' ce rea ls into combina t ions were identi f ied a s the mos t c o m m o n feed ing s t ra teg ies / techn iques used by the mothers in this study. M a n y mothers d e s c r i b e d us ing the 'swi tch ing ' (7/12) st rategy and the 'mix ing' (6/12) st rategy in response to their percept ion that their infant d is l iked infant ce rea l . However , all of the mothers 71 RESULTS (12/12) in this s tudy desc r i bed us ing the 'mix ing ' s t rategy in order to c h a n g e the taste or texture of different foods . T h e mothers who u s e d the food 'swi tch ing ' s t rategy a l so appea red to do s o to promote sol id food a c c e p t a n c e . F i ve of the s e v e n mothers in this group ci ted 'swi tching' a s a feed ing strategy that they spec i f ica l ly u s e d with commerc i a l infant ce rea l s . O n e mother f inally sw i t ched food g roups f rom infant ce rea l to s ing le fruit and vege tab les before the infant accep ted so l id foods . Ano ther mother art iculated 'swi tch ing ' within her meat feed ing pract ices to promote meat a c c e p t a n c e by her infant. T h e fo l lowing quotes il lustrate the c o m m o n feed ing s t ra tegy/ technique 'swi tch ing ' . T h e s e mothers sw i tched to another type of ce rea l , for examp le , r ice to oat ce rea l , and brand of ce rea l , for examp le , M i l upa to G e r b e r . T h e 3 mothers are c lear ly tai lor ing their feed ing s t rategies in r e s p o n s e to their infant's food p re fe rences . "He didn't really like the rice cereals and then I think I switched to an oatmeal cereal for a brief time. Neither one did I finish the box and he didn't like it that much and now I use the Milupa mixed cereal and it's a lot more expensive but he likes it a lot better (10-112)". He didn't like the rice a first but then he loved barley and oatmeal [cereal] (2-214). "I was giving her the Milupa, and I wasn't having any success with that at all. So I started giving her the Gerber and some days she'd like it and some days she wouldn't. And now I have the Gerber [mixed] with fruit and she just loves it (12-223"). S o m e infants were less 'accep t ing ' of the ce rea l s they were fed . ' A c c e p t a n c e ' c a n be identif ied by the length of t ime it t akes the infant to eat the food routinely. It s e e m s poss ib le that the var iat ions in the transit ion p a c e identif ied a m o n g the mothers m a y be related to the use of spec i f i c feed ing s t ra teg ies / techn iques. T h e mother in the last quote (12-223) stated that it took a month and a half to f inal ly f ind a ce rea l the infant wou ld eat. T h e fol lowing mother desc r i bed the 'mix ing ' strategy. Howeve r , this quote i l lustrates a negat ive c a s e s ince the infant con t inued to re fuse the infant ce rea l even though the mother u s e d the 'mix ing ' strategy. T h e transit ion graph (number 3) (Append ix G ) for this infant s h o w s con t inuous ly low ce rea l consumpt ion be tween 5 and 7 months of age . Th i s mother f inally, after 2 months , sw i tched to giving fruit a lone rather 72 RESULTS than mixing fruit with c e r e a l . It is not c lear f rom the ava i lab le da ta 'how' the mother 'm ixed ' the foods together. A l though infant ce rea l a c c e p t a n c e a p p e a r s to b e i nc reased by us ing the 'mix ing ' strategy, the w a y the mother m ixes the foods together is a l so c lear ly important. "We have established that he doesn't like cereal and the only way we can really get him to take it is by mixing it with the fruit or vegetables., .but he will still turn it away (3-647). He just doesn't like cereal, so I kind of think he was ready before...he just wasn't getting what he wanted because as soon as we offered him a jarred pureed fruit he loved it, he loved it... like right away (3-667)". T h e most f requent 'way" that the mothers in this s tudy ' tai lored' their dai ly feed ing strategy or techn ique w a s by 'mixing'foods. S imi la r to 'swi tch ing ' , the reason mothers gave for mix ing foods together w a s to p romote food a c c e p t a n c e . T h e fo l lowing quotes il lustrate the mother and infant r e s p o n s e s , spec i f i c to feed ing ce rea l s and e m p h a s i z e the link be tween the techn ique used a n d the mothers ' pe rce ived r e s p o n s e s . T h e s e c o n d quote i l lustrates the comp lex mixtures that the mother c rea ted in r esponse to her infant 's refusal of sol id food. T h e s e c o n d quote and the p rev ious quo te , aga in sugges t that the 'way 5 that the mother m ixes foods into combina t ions m a y have d e c r e a s e d the a c c e p t a n c e of ce rea l . T h e ava i lab le da ta sugges t that it is c lear ly poss ib le that the mother m a y c rea te mixtures that the infant d is l i kes . "So he eats it much better now [cereal] because I will mix it..(1-140)... So either I mix it with a vegetable or I mix it with a fruit (1-407)". "He takes oatmeal and rice cereal and he doesn't like the taste of it so we do have to mix it with fruit to camouflage it. ..so I have been trying to give him a fair bit of cereal mixed with his fruit, when he has breakfast, and with his dinner fruit and with his lunch fruit actually, I just put it into all the fruit (4-70) Initially he really liked it (rice/oatmeal cereals) and then he just wouldn't take them any more (4-235)... Probably 5 Vz months he wasn't interested in any cereal... I tried different ones the ones with banana, the ones with vegetable and I was you know and then someone suggested trying the Milupa and he didn't ever like Pablum for some reason but he's always liked Milupa and ya and then I started mixing it with a little bit of fruit juice and then I thought maybe I shouldn't do that but ahhh there is so many question marks, whatever they will take, so then I don't know if that is what's given him a sweet tooth because I started to mix cereal 73 RESULTS with pear juice or apple juice or and I buy the baby juice and mix it a little bit to make it a bit sweeter and then when he stopped taking that then...about 5 ¥2 months then it wasn't sweet enough for him or something so then I started mixing it I would mix it with fruit juice AND with his fruit....so double wammy (4-242-268). Around the Cheerio time started giving him yogurt but he doesn't like the plain yogurt by itself so I mix it with the fruit and cereal and hide it in there (4-671) Infant c e r e a l 'mix ing ' w a s a cons is ten t t h e m e a c r o s s the interviews. T h u s , 'mix ing ' techn iques were sor ted in order to desc r ibe them in more detai l . T h e mothers desc r i bed 3 'ways ' that food mixtures were fed to their infants. It s e e m s poss ib le that the different mix ing techn iques that the mothers u s e d cou ld potential ly in f luence ce rea l a c c e p t a n c e differently. T h e first mix ing variat ion desc r i bed by the mothers (4/12) w a s feed ing ' commerc ia l l y p re-mixed comb ina t ions of infant ce rea l or meat with a d d e d fruit or vege tab les . T h e first quote i l lustrates the first mix ing var iat ion. T h e s e c o n d mix ing var iat ion identi f ied f rom the sort ing w a s where the mother (6/12) 'made her own mixture' us ing s o m e combina t ion of breast milk, formula, fruit, vege tab les , or yogurt m ixed with the c o m m e r c i a l infant c e r e a l . T h e s e c o n d quote i l lustrates the s e c o n d mix ing var iat ion. In contrast to the prev ious quote, t hese quo tes il lustrate increas ing infant ce rea l a c c e p t a n c e . "He just kind of, in the last week probably, really kind of jumped up on his quantities. Before we would have been doing say, 2-3 tablespoons and now we are doing a full 3-a full 4 tablespoons, so he will have 4 tablespoons of cereal in the morning... I mix that with formula., we either do the mixed cereal with banana or with mixed fruit (6-234)". "Twice a day morning and night (cereal)... Just with fruit I have never mixed it with vegetables. And I mix it with formula too. I've been mixing it with formula umm since he started eating more at about five months (8-121)". T h e third mix ing var iat ion desc r i bed by the mothers ' (4/12) w a s feed ing infant ce rea l with fruit or vege tab les 'on the s ide ' of the plate dur ing the meal t ime. T h e fol lowing quote i l lustrates the 'on the s ide ' mix ing techn ique . T h e s e q u e n c e that foods are fed is of part icular interest, s i nce the quanti ty of infant ce rea l a c c e p t e d by the infant m a y differ depend ing on the s e q u e n c e in wh ich it is fed . T h e mothers in the fol lowing quo tes fed the infant ce rea l after the other so l id 74 RESULTS foods they were hav ing at that part icular mea l t ime. It s e e m s poss ib le that if infant c e r e a l s were fed last in a feed ing s e q u e n c e , l ess iron fortif ied infant cerea l m a y be c o n s u m e d due to sat iety. "One meal in the evening... a big portion like about ...three quarters of a cup...oatmeal [commercial cereal] ...mixed, but it was mixed quite dry [with formula]...we had like a teaspoon [fruit or vegetable] it would sort of be on the top. I wouldn't mix it in but I would give him both in one spoonful until he finished the vegetable and then he'd just get oatmeal (Heinz Mixed Greens) (9-175)." "What I do when I give him a meal is I give him umm... first off I give him I offer him the vegetable like say it's carrots and then I'll offer him the combination of the vegetable with the meat one and then usually between those two I will get in about eight bites on the average I would say between those two eight little baby spoonfuls. An then and then when he seems to fuss and he doesn't want anymore I know he's just fed up then I give him then I always have the fruit mixed with the oatmeal one it's about 1A and Ife or maybe 1/3 oatmeal 2/3 rds fruit I just use oatmeal Milupa mixed with a wee bit of fruit juice (4-781)". T h e quo tes il lustrate var iat ions in food mixtures be tween mothers. T h e 3 'ways ' of mixing ce rea l s , a l though sl ight ly different, cou ld b e c o n s i d e r e d a ' complex ' food comb ina t ion . Interestingly, of the numerous food mixtures fed , none of the mothers mixed infant ce rea ls with meats . T h e mother ' s mix ing combina t ions m a y in f luence infant a c c e p t a n c e a n d wou ld differ in dietary iron content a n d food componen ts that e n h a n c e or inhibit iron absorp t ion . C lear ly , the food 'mix ing ' t echn iques that mothers u s e cou ld in f luence iron avai labi l i ty (i.e., depend ing on the infant 's a c c e p t a n c e a n d the ratio a n d the t ypes of f oods m ixed together). T h e fo l lowing quote i l lustrates a mother ' tai loring' her feed ing s t ra tegy by adapt ing the food mixture in r e s p o n s e to her infant's food p re fe rences . T h e total d ietary iron content of the food combina t ion f rom this mixture is related to the ratio of h e m e iron prov ided f rom the meat mixed with the amoun t of non -heme iron prov ided f rom the vege tab les . F o o d 'mixture ' var iat ions - the ratio of fruit or vege tab les to ce rea l or meat , di f fered be tween the mothers in this s tudy. 75 RESULTS "...3 weeks ago [at 7 months] I started chicken and beef ...I made it myself. Home made. Mashed or pureed it up and I really have to mix it. I would almost say like ... a ratio of one to four with vegetables for him to eat it ... (6-197)" T h e ava i lab le da ta sugges t that the feed ing techn iques 'offering' and 'wait ing' m a y be less effective feed ing s t rategies than 'swi tch ing ' a n d 'mix ing ' at promot ing infant ce rea l accep tance . Further, the infant's transit ion p a c e a p p e a r s to be s lower w h e n the former strategies were u s e d . Howeve r , a l though the 'mix ing ' food techn ique w a s desc r ibed by m a n y mothers a s one w a y of p romot ing infant ce rea l a c c e p t a n c e , seve ra l mothers a p p e a r e d to have s o m e difficulty creat ing mixtures that their infant a c c e p t e d . 4.5.3. Ways of feeding; adjusting feeding management Half of the mothers in this s tudy desc r i bed us ing a feed ing s t ra tegy/ technique that w a s labe led 'adjust ing feed ing managemen t ' a s a 'way" to promote sol id food a c c e p t a n c e (i.e. cerea l ) . T h e mothers d e s c r i b e d two different feed ing m a n a g e m e n t behav io rs . T h e mothers ' behav iors inc luded either l imiting the l iquid food in the diet and /o r adjust ing the t iming be tween feed ings . T h e fol lowing quo tes i l lustrate the ' w a y that t hese mothers were ' tai loring' their feed ing strategy in order to p romote ce rea l a c c e p t a n c e . T h e fo l lowing two mothers d i s c u s s e d limiting the liquid port ion (breastmi lk , formula) of the diet. "And just that I would give in because I felt he wasn't getting enough (1-2079). You see but now he is at this stage he is... I don't give in and he'll eat a substantial amount [cereal] that I know he has had enough and then if we are out for the day I will bring that sort of a bottle of juice...and ummm you know I really limited the breast-feeding to I think let's see...like maybe 4 or 5 feedings a day so I don't like I don't like whip it out [breast] and feed him any old time like I did before (1-2073). "So I don't give her another [bottle] one in the morning. So at breakfast time she's ...ya she's hungry, she's hungry at breakfast so that's she has the cereal then and she really likes it (5- 429)". 76 RESULTS Three mothers discussed adjusting the timing of feeding. The following quotes highlight the importance of the 'timing' between solid and liquid foods and the mother's perception of her infant's hunger. The last quote describes a mother 'tailoring' her feeding strategy by adjusting the timing between meals. This mother describes a flexible 'on demand' solid food feeding style, using food hunger cues to guide mealtimes, whereas the first 2 quotes describe 'limiting' the liquids in the diet to influence solid food consumption. In this last quote, the mother's 'mealtime' flexibility is emphasied by her statement that "dinnertime can be anywhere from 4 - 7pm". "In the morning I want to make sure she gets the cereal into her before I will give her her bottle and if she doesn't eat very much cereal I don't give her a bottle. I will wait for another hour maybe (11-191)... I think it's just its all timing, how hungry is she, how active has she been (11- 343) When I can get him in a good mood or, you know, try to coordinate it so that he hasn't just had a bottle,., you know, so that we've got enough space and time kind of between bottles that where he is hungry. You know there are times where he'll just like, eat, eat, eat (7-662)". "I don't know that we are necessarily doing anything that is working well. We're just basically following his... his lead, if he likes something we go with it. If we don't, ifs not that big a deal. ...for us and for the way (the baby) is, it works really well to do that. To let him tell us when he is hungry... We feed him when he is hungry. Like dinnertime can be anywhere from 4:00 till 7:00 depending on...on when he's hungry (9-760)... Then to sometimes he'll fuss at 4:30 and we think he is hungry so we get everything ready and then he doesn't want to eat. But so we just, that's not it. So we just put it back in the fridge (9-784)". 4.5.4. Ways of feeding; socializing, modeling, engaging, playing Several mothers used feeding strategies that appeared to be related to the 'social' aspect of the feeding experience. These strategies focused on using positive reinforcement and were interactive. These strategies were labeled as socializing, modeling, engaging and playing. 'Socializing' means the parent(s) were encouraging 'family mealtimes'. 'Modeling' means the feeder was teaching the infant how to eat the food. 'Engaging' refers to letting the infant play with the food utensils while feeding the infant to give the infant some 'control' during the mealtime. Lastly, food 'playing' refers to allowing the infant to explore and play with the food itself. The 77 RESULTS fo l lowing s ta tements highlight the connec t ion be tween the mother 's feeding strategy and her percept ion of the feed ing expe r i ence ; " i t 's more re laxed that way. . .no t hav ing to rush a round ' and "he definitely enjoys his food more" . T h e mothers s e e m e d to fee l , in part icular, that 'eat ing together" w a s an important factor that i nc reased the infant's meal t ime enjoyment. O n e mother in this g roup art iculated a deta i led accoun t of the four techn iques in this sec t ion . T h e text h a s b e e n inc luded to il lustrate the use of mult iple ' soc ia l ' feed ing techn iques (Append ix H). "And we always eat at the same time, we try and eat together like when he's having breakfast I'm having breakfast and when he's having dinner we are usually having our dinner. And I find he's a lot more relaxed that way like. Sort of make mealtime, mealtime for everybody. And I find ifs a lot more relaxing that way and you are not rushing around to feed him and then rushing around to get our dinner ready and then keep him entertained while we eat (10-603)... I read in books...[it is] important...[to] play with food...[I am a] neat freak...[but I am] getting use to ...[the] mess is hard...[but] it's what they like...[To] Explore and stuff every once [in awhile]...you don't have to do it all the time but every once in awhile [to let them] explore with their food (10- 894/909)." "He definitely enjoys his food more when we give it to him when we are having our meal and I notice he likes to socialize and as soon as he sees us eating he is quite happy to sit in his high chair, we put it right here in between us. Ya and before we were trying to feed him before we had our dinner and settle him and put him to bed and then have our dinner when it was peace and quiet but now we find that no.. he loves the socialization of the meal you know and... it just makes it more fun than [before]. ..he enjoys his meal although it's a bit difficult for the mom or dad to eat. ..but I notice he is much happier if he eats when we are eating (4-843). 4.5.5. Ways of feeding; positioning A few mothers desc r i bed a feed ing techn ique that w a s labe led a s 'posi t ioning ' . T h e first quote i l lustrates how one mother adap ted her feed ing strategy by chang ing the 'posi t ion ' that the infant w a s fed . T h e infant w a s f ed wh i le lying flat o n h is b a c k rather than sitt ing up to eat, in order to i nc rease the quanti ty of so l ids her infant c o n s u m e d . T h e mother used this techn ique for the first month of feed ing ce rea l a n d s ta ted that the infant ate a larger quanti ty and ate happi ly in this posi t ion. T h e s e c o n d quote i l lustrates another examp le of the mother adapt ing her feed ing strategy (the 'posi t ioning' technique) to get food ea ten by the infant. In this c a s e the mother 78 R E S U L T S appea rs to be ' restrain ing' the infant in a ca r sea t to c a l m him enough to get him to drink a bottle. Th i s mother e x p r e s s e d c o n c e r n about the difficulty of feed ing sol id food c o m p a r e d with giv ing a bottle. Bo th of the fo l lowing quo tes a re e x a m p l e s of the 'posi t ioning' technique. T h e ava i lab le da ta sugges t that a l though feed ing in the ' lying posi t ion ' m a y increase sol id food consumpt ion for this part icular infant, ' restra in ing' the infant and feed ing liquid foods rep laces the so l ids and m a y de lay the so l id f ood transi t ion p r o c e s s . "As far as the even feeding the cereals and that, umm, he wouldn't you'd start feeding him sitting up or, for a while there he was just sitting in my lap and I was feeding him, and he'd take a little bit of it that way and then he would quit taking it. But if you put him flat on the floor and he was lying flat on his back he would eat and he was like that for about the first month of giving him cereals...! remember we were even doing vegetables when he was flat on his back...quite happy to eat that way. Yeah, because you would almost think he would be more likely to choke on foods but he would eat foods quite happily on his back whereas he would stop eating if you still had him sitting up (6-954)". "umm trying to keep the long term goal and umm and so I guess that's my biggest concern is that it is just so difficult [feeding solid foods], so much easier...to give him a bottle like you know, because I can strap him down for a bottle in his car seat and calm him down enough to get him to focus on eating but right now he just wants to .. .play he doesn't want to miss anything (7-577)". 4.5.6. Ways of feeding; distracting, or sneaking/camouflaging food S e v e r a l mo the rs d e s c r i b e d us ing a feed ing techn ique that w a s labe led a s 'd istract ing' . T h e mothers u s e d food toys to distract the infant whi le spoon- feed ing , in order to get the infant to eat the sol id food . Bo th mothers , in the fo l lowing quo tes , perce ived that the infant en joyed ' chewing ' o n the food toys dur ing the mea l t ime. "He really likes, he really likes chewing on his spoon. And so I use that, where I give him his own spoon so he can chew on it and then [ij put in [the] food, so he's playing with that.... (7- 662)". 79 R E S U L T S "Usually now when I feed him he has his food toys. Some toys are for use when he's feeding. He likes them. He gets bored... So there are 3-4 toys that are just to play with food...he usually chews on it (2-1038)". S e v e r a l mothers a l s o d e s c r i b e d a n infant f eed ing techn ique that w a s labe led a s ' sneak ing ' or ' camouf lag ing ' . T h e mothers a p p e a r e d to be tai lor ing their feed ing strategy by sneak ing (changing feed ing s e q u e n c e ) or camouf lag ing (mixing d is l iked with l iked foods) the sol id food . For examp le , the fo l lowing mother fed the ' l ess accep ted ' meat r ice combinat ion before the ' accep ted ' y a m s . T h e mother in the s e c o n d quote, m ixed l iked and d is l iked foods together, in order to hide or camou f l age the d is l iked sol id food in the combina t ion . T h e food 'mix ing ' techn ique has b e e n prev ious ly d i s c u s s e d . Mix ing foods together into comp lex food combina t ions m a y poss ib ly h a v e 2 different o u t c o m e s . A s prev ious ly d e s c r i b e d , the mix ing techn ique s e e m s to be used by mothers to tai lor the taste or texture of the food combina t ion , in r e s p o n s e to the infant's food p re fe rences . T h u s , promot ing sol id food a c c e p t a n c e . Al ternately, in this c a s e , the food 'mix ing ' techn ique a p p e a r s to focus on sneak ing or camouf lag ing d is l iked foods with foods the infant l ikes. It is not c l ea r if, or to what deg ree , the food is a c c e p t e d by the infant, us ing this strategy. Further, it is not c lear , but s e e m s poss ib le , that longer term enjoyment of spec i f ic so l id foods m a y d e c r e a s e w h e n us ing t hese st rategies - d istract ing, sneak ing /camouf lag ing . 'Wnaf / will do is if I want him to eat that I'll bring out something that he likes and try to give him a spoonful of the chicken and rice that he wasn't too interested in and then give him a couple of spoonfuls of yam (10-827)". "She didn't like them because they have a sort of metallic kind of taste... those little jars... the meat [commercially prepared meats] it's umm... it's very tacky... it's grainy. I have to hide it in like a lot of vegetables or something... She bouck's [gags] on it (5-483)". 4.5.7. Ways of feeding; prying, stuffing or forcing A few mothers (3/12) c o m m e n t e d on their initial u s e of a feed ing techn ique that w a s labe led pry ing, stuffing or forc ing sol id food . T h e e x p r e s s i o n s u s e d by mothers to desc r ibe these techn iques w e r e " pry with m y s p o o n , s h o v e the food in, a n d w h y a m I forc ing him to eat this". 80 R E S U L T S T h e s e mothers a p p e a r to have used t hese st rategies initially, and then later tai lored their feed ing techn iques (or m a y b e ad justed their percep t ions about their infant's food needs) in response to what a p p e a r e d to be negat ive feed ing d y n a m i c s . T h e fol lowing quote sugges ts that the mother s e e m s to be c o n c e r n e d about the infant not 'gett ing e n o u g h ' food and not eat ing ce rea l . A mother 's ' conce rn ' about so l id food reject ion m a y inc rease the use of these speci f ic feeding techn iques (forcing, prying and push ing so l id foods) . T h e fol lowing quote a lso s e e m s to sugges t that the mother is inexper ienced in feed ing and that s h e is mov ing through a learning ' p rocess ' poss ib ly trying to f igure out 'how' to f e e d her infant. "Just initially when he was... when I was trying to get him to eat stuff [rice cereal] that either he didn't like, or I don't know, he was just fussy, like he would play with this and he would start putting it [a toy] in his mouth and I would shove the food in. But you are not supposed to know that (2-1057)... I remember being worried about, like initially, I guess, when we were giving him cereal and he wouldn't take it and I tried to pry my spoon, but I know I shouldn't have been doing it (2-1169 )...Like he would play with this [toys] and he would start putting it in his mouth and I would shove food in (2-1064)... But you are not supposed to know that (1065)... Just like.. .[I] shook something just to try to get his mouth open ... so I can feed him (2-1088)... I mean, if he doesn't want it he doesn't want it. I mean, he's not going to starve. But initially you think, oh, he has to eat, and you now ummmm the books say you should get so much of this, so much fruit, so much, and that means you have to go by. But I mean ifs not a big deal, you know, one day he just eats, you know, crackers and toast (2-1174-1183)". 4.5.8. Ways of feeding; pushing 'Pushing' w a s a s t rong t h e m e that evo l ved f rom a c r o s s more than half of the interviews (8/12). T h e concep t ' push ing ' has 2 different interpretat ions. T h e mothers appea red to be 'push ing ' the so l id food itself and /o r ' push ing ' the transit ion p a c e , f rom a liquid to a mixed food diet. T h e two reasons for ' push ing ' foods were conce rn about returning to work and concern about the infant 's ou t come (food refusal and weight gain) . It s e e m s poss ib le that 'push ing ' food or the transit ion p a c e m a y reflect the mothers ' r e s p o n s e to so l id food feed ing conce rns in genera l . T h e mother 's work force part ic ipat ion appea rs to have in f luenced, to s o m e degree , subsequen t feed ing behav io rs . F o u r mothers in this s tudy were intending to or had a l ready 81 RESULTS returned to work. T h e ava i lab le da ta sugges t the mothers were 'push ing ' the transit ion p r o c e s s in order to return to work. T h e s e mothers u s e d ph rases l ike, "won' t have to wor ry ' , and " s o that I cou ld know that he wou ld be fine w h e n I w a s a w a y , to exp ress s o m e of the emot iona l and organ iza t iona l i s s u e s a round so l id food feed ing a n d leav ing their infant, in order to return to work. T h e first two quo tes il lustrate the impact of returning to work on these mothers ' sol id food feed ing prac t ices . It s e e m s poss ib le , that the postnata l t ime line when the mother must return to work, m a y inf luence the age sol id foods a re in t roduced a s wel l a s the p a c e mothers ' transit ion' f rom the liquid diet to a m ixed diet that inc ludes so l id foods . When I go back to work in September and he is going to go into the daycare, the infant daycare, I mean the philosophy there is the same way. The kids self-help skills start so young and I just think the more you encourage it... independence and doing stuff on their own it just builds their self confidence and you know like food is something that they have power over (1- 1084)... I'm thinking maybe he is just still seven months like my friend would say and maybe I am trying to push him too much but then I have to think about when I go back to work...in a daycare probably by August...(1-2337)... [He] will be well on his way [to eating foods independently]...[I] won't have to worry (1-2378) Just once a week (work), but it still meant that there was something that needed to happen if I was going to leave him for the majority of the day because he wouldn't have anything to eat because he was not eating solids at that time and he didn't want to have solids for a long time (3-97)... Just for realism, so that I could know that he would be fine when I was away we needed to have him be eating solids. When I was leaving him for a full day but not just 4 hours or whatever (3-510)... Just physically being away from him has sort of demanded that I find an alternative for him to have when I am not there and that has aided in weaning him from the breast (3-838)." T h e fol lowing mother s ta ted that s h e would not be ab le to return to work when s h e e x p e c t e d b e c a u s e of the difficulty s h e w a s exper ienc ing with the so l id food transi t ion p r o c e s s . T h e fol lowing quote sugges t s s h e is c o n c e r n e d about , the quant i ty of so l id foods her infant is accep t ing , how quick ly he is p rogress ing in the transit ion p r o c e s s and the infant 's refusal of infant fo rmula in a bottle. 82 R E S U L T S / would actually like to breast-feed him to a year but unfortunately it is not going to work with me going back to work and me having to be away for 13 hours (4-114)... Because now that breast milk is being weaned a little bit he's you know he's going to need to have more nutrition from other sources (4-352)... I'm I'm quite worried about getting him he's got to start taking more (4-359)... And that's the other thing we've been trying to kinda get him on the bottle but he won't take the bottle (4-577)... I am suppose to be back to work mid November...casual but I think ahh I probably won't be taking any shifts for a long time until he is off you know because I am not going to let him go hungry (4-639) Interestingly, the fol lowing mother s e e m s to be tai loring her infant feed ing rout ines to the future dai ly rout ines s h e expec ts to have w h e n s h e returns to work. T h e s e c o m m e n t s reflect the c o m p l e x emot iona l and organ izat iona l i s s u e s invo lved in the mother 's preparat ion to return to work. T h e link be tween the ' cons i s tency of dai ly feed ing rout ines' and the infant's a s wel l a s the careg ive r ' s 'expecta t ions ' about feed ing a p p e a r e d to be important to this mother, in order to m a k e her transit ion f rom be ing at h o m e to be ing at work , eas ie r . Further, the mother, a s the quote sugges t s , must ' transit ion' f rom being the pr imary feeder to hav ing a careg iver take over the feed ing ' ro le ' , dur ing the day t ime. T h e mother a p p e a r s to be consc ious l y tai loring her feed ing rout ines in order to ' push ' or promote a s u c c e s s f u l transit ion for w h e n s h e returns to work. "Trying to get into stricter routine (11-154)... Back to work (next month) (11-165)... Starting at 6 months I started trying to impose a bit more of a schedule on her...umm but slowly so that it was still flexible and now she's 7 months and I want things to get just a little bit more strict just so that I can let her caregivers know what what to expect in the day and that she's [the baby is] going to know what to expect in a day, even if I'm not there (11-690)". S o m e mothers ' (3/12) a p p e a r e d to be tai lor ing their feed ing strategy by 'push ing ' food b e c a u s e of their percept ions about the infant not ga in ing weight and/or not accep t ing foods . T h e s e mothers used p h r a s e s s u c h a s " s topped ga in i ng " , "trying to feed h im a lot" a n d " I w a s real ly wor r ied ' to exp ress their c o n c e r n . T h e first quote i l lustrates the mother 's food spec i f i c 'push ing ' behav io r where s h e s e e m s to tai lor her l iquid feed ing strategy to " feed him a lot" b e c a u s e s h e is "worr ied about we igh t ' . T h e s e c o n d quote desc r i bes a mother not ' push ing ' so l ids but ins tead 'wait ing' for the infant to ' b e c o m e interested ' in ce rea l s . It is poss ib le that the food 83 RESULTS 'pushing' strategy would develop further, with dimensions ranging from' pushing' to not 'pushing' or 'waiting', with more focused interviewing and analysis. It seems possible that a mother may either 'push' or not 'push' foods (i.e. wait) in response to her level of infant feeding experience. Learning to feed solid foods and the mother's process of 'gaining feeding expertise' is discussed in detail in the next section. "Stopped gaining weight around 6 months.. .And the doctor didn't seem too concerned... he seems to be getting longer but just not heavier...that was bothering me (7-836)... [I am] trying to feed him a lot... worried about weight... I am not trying to focus so much on solid foods.. ..bottle... QUICK (7-872)". "I was really worried... Yeah, and I was going to the mothers groups and asking about it, and they said don't worry about it, don't worry about it (o'kay). And it then at six and a half months she hadn't gained any weight in close to two months (oh o'kay). She had stayed the same weight. And they were still saying don't worry, don't worry, she will get interested and eventually she did, but... I was really worried about the weight gain, and I had heard about other babies that were feeding at four months. You know, infant cereals and were fully interested, and she wasn't (12- 526)." 4.5.9. Ways of feeding; holding back food Many mothers described a feeding strategy that was labeled as 'holding back' foods. Specific foods were 'held back' or not fed to infants for 3 main reasons. The mothers in this study appear to have 'held back' specific foods because of the characteristics of the food (e.g., texture difficulties, the risk of tooth decay, food processing concerns and the risk of food allergy/sensitivity). The mothers also 'held back' food because of their perceptions about infant readiness (i.e., infant not ready for foods) and their personal purchasing decisions (i.e., availability of food). The types of food that individual mothers 'held back' included fruit or juice, mixed cereals, meat, finger foods, dairy, formula and breast milk and processed foods. Half of the mothers in this study described 'holding back' behaviors because of their concern about the infant choking or having difficulty with the texture. The following two quotes illustrate the mothers' 84 RESULTS conce rn about texture and chok ing . T h e mothers conce rn s e e m s to inf luence the infant feed ing p r o c e s s - the introduction of spec i f i c so l id foods and the transit ion p a c e . "Actually I haven't made any of my own food... I was so worried about texture and choking that I've just been getting the ultra strained...so very pureed...pureed (4-269)... [I] Haven't tried [new recipes], because of the texture (4-509)". "Ihave been concerned about him choking ...like, how do you start introducing things like toast and bread and Cheerio's and stuff like that...he tried to swallow it, so of course he choked on it, and threw up, most of all of his other meal that he'd just had. That was the end of the Cheerio's...Melba toast...he ends up with this big piece broken off. It's got this really sharp end on it, so I just freak and I figure he's going to choke on it and I take it away from him... What, how do you get them on, what is there that you can give them that you don't need to be quite so. ..ahh afraid of the choking (6-462)... I am taking it fairly slow on the meats...more difficulty with the texture (6-297)". S e v e r a l (5/12) mothers c o m m e n t e d on holding back foods b e c a u s e of health c o n c e r n s . T h e s w e e t n e s s of the food a n d risk of tooth decay , with regards to ju ice, w a s a c o m m o n conce rn . Spec i f i c foods not be ing a s nutrit ious a s others , was a l so a conce rn (i.e., red meats or fruit not be ing a s nutrit ious a s white mea ts or vege tab les ) . P r o c e s s e d commerc i a l foods with ingredients s u c h a s preservat ives , we re a conce rn to s o m e mothers . Last ly , conce rn about future weight p rob lems , w a s d i s c u s s e d . T h e fo l lowing quo tes il lustrate how the mother m a y tailor her feed ing st rategy acco rd ing to her percept ions about the 'character is t ics of the food ' . T h e quotes a lso sugges t that these mothers a p p e a r to be in f luenced by what they pe rce i ved w a s 'healthy 1 a n d 'nutrit ious' food . "Meats...go towards tofu, cheeses & fish...yogurt (1-920)". "I didn't introduce apple juice until umm, quite far along the way. I'm not, although I think that apple juice has a lot to offer I am not that crazy about it for young babies. You know, it's not good for their teeth and it's sweet, so (3-969)... We don't eat a whole lot of meat at our house... red meat anyways. We eat mostly chicken and fish and we do eat red meat only once a week so I'm not. ..as long as he is having proteins and he is already having breast feeds so I am not too worried about his meat intake (3-740). ...I get grossed out when I look at some of the 85 R E S U L T S ingredients on like Heinz and those jarred things so I.. .prefer to keep it as sort of natural as possible so. (3-702)... I try to do things that are healthy... I know that it's healthy for children to be breast fed...It's healthy for them not to have preservatives in their food... that fresh fruit or vegetables are best and those are the things that I think about for my children (3-906)". "I didn't give him apples or pears very much because I think the squash and the...the green stuff is more nutritional. Full of nutrition, is what I'm trying to say. So I would give him that, and I really watch that... So he gets pears and apples and stuff as a treat (9-423)... I look at, umm I look at color. I try to, I try to find ahh, I don't buy anything with any added sugar or salt or anything in it except the vegetable and water.. .[I am] worried about giving him too much stuff... He is a big boy... Having him eat too much...I don't want him to have a weight problem (9-1021)". S e v e r a l mothers held back spec i f ic foods (mixed ce rea l s , fruits, and dairy) b e c a u s e of their percept ions about the risk of a food al lergy. T h e food 's a l lergy ' l ikel ihood' s e e m e d to inf luence the mothers ' dec i s i ons about what w a s fed . T h e mothers who were c o n c e r n e d about a l lerg ies c o m m e n t e d on what not to g ive their infant at spec i f i c a g e s (e.g., mixed ce rea ls and dairy). T h e fol lowing quote a l s o in t roduces the concep t of feed ing ' one food at a t ime' before mov ing on to a different food . It s e e m s highly l ikely that mothers will differ in their feed ing prac t ices with regards to so l id food p rogress ion . F e e d i n g 'one food at a t ime' before mov ing on to a different food m a y d e c r e a s e the transit ion p a c e , depend ing on how the mother p r o c e e d s . "/ didn't because you are not supposed to until they are 6 months [introducing mixed cereals] And also I believe in doing like one type of food at a time. And they are mixed so he wouldn't be able to do that, so just for allergy purposes ... (3-628)... I didn't feel that he was ready for it (meat) anyways. I think you are not supposed to start them until 8 months...so I just discontinued it (3-726)". T w o mothers c o m m e n t e d on 'hold ing back ' mea ts , however , they did s o for different reasons . T h e first quote i l lustrates the inf luence of the mother 's percept ion of infant deve lopmenta l r ead iness (be ing hard on the infant's s tomach) on feed ing dec i s ions , w h e r e a s the s e c o n d quote sugges t s that the food (meat) avai labi l i ty m a y inf luence the mother 's meat feed ing pract ices. 86 RESULTS "Sometimes if I give him beef. What I usually do is I try and alternate giving him meat one day and the next day I don't give him a meat, just incase it is hard on his stomach. Like I try, I don't try, I try not to give it to him twice two days in a row... Try not to give 2 days in a row (10- 247)". "Doesn ' t ' get protein eve ryday [commerc ia l ly p repared meat combinat ions] . . . i f we ' ve got one open. . . [We] use [it] up o n c e [ i ts]opened (11-805)" . T w o mothers c o m m e n t e d on the i d e a of 'potential ly' inf luencing infant food pre fe rences by 'hold ing back ' spec i f ic foods . T h e fo l lowing two mothers both ' l imited' the l iquids in their infant 's diet ( formula and breast milk), in o rder to inf luence ce rea l a c c e p t a n c e . T h e first mother a l so 'he ld back ' fruits b e c a u s e s h e pe rce i ved that it wou ld inf luence or promote her infant's a c c e p t a n c e of vege tab les . 'Limit ing" the l iquid port ion of the diet w a s prev ious ly d i s c u s s e d in the sec t ion d i scuss ing the feed ing techn ique 'adjust ing feed ing managemen t ' . T h e quotes a re p resen ted here to e m p h a s i z e the similar i ty be tween the two concep ts - hold ing back food and limiting food . Ho ld ing back foods , a s d i s c u s s e d in this sec t ion , is a techn ique that mothers use , speci f ica l ly , b e c a u s e of their percept ions about the character is t ics of the food itself (concern about chok ing , texture difficulty, a l lergy risk, tooth decay , food p rocess ing c o n c e r n s , difficult to d igest , and food avai labi l i ty). T h e mothers w h o ad justed their feed ing m a n a g e m e n t by 'l imiting' or 'hold ing back ' l iquids o r other f ood s u c h a s fruit a p p e a r e d to d o s o to in f luence the infants' f ood p re fe rences . T h e 2 concep ts - limiting a n d hold ing back m a y deve lop a long a d imens ion within the 'adjust ing' feed ing m a n a g e m e n t techn ique with further interviewing and ana lys i s . "So in the morning I want to make sure she gets the cereal into her before I will give her her bottle and if she doesn't eat very much cereal I don't give her a bottle. I will wait for another hour maybe (11-191).... Still hasn't had any fruit... I'm holding off on sweet stuff just cause I know she's gonna take it I know that's not an issue (11-111)... I'm just hoping that umm if she gets to like the vegetables she's not going to decide that she doesn't want them anymore if she can have fruit just cause she's had them for so long and they are just a part of her day (11-120)". "Reached this point..He knows this is his feed... I'm not going to breast feed him (1- 2000)... Now he is at this stage he is... I don't give in and he'll eat a substantial amount that I know he has had enough and then if we are out for the day I will bring that sort of a bottle of 87 R E S U L T S juice...and ummm you know I really limited the breast-feeding...like maybe 4 or 5 feedings a day so I don't like whip it out and feed him any old time like I did before (1-2079)". 4.5.10. Solid food feeding strategies summary. T h e number of so l id food feed ing st rategies u s e d by the individual mothers var ied f rom 2 to 7 (Append ix I). A l though the abso lu te number of s t rategies u s e d by e a c h mother may, to s o m e deg ree , reflect that the mother is tai lor ing her infant feed ing strategy, it d o e s not c o n v e y how the different s t ra tegies that the mother u s e s cou ld potential ly in f luence dietary ou t come differently. T h e s u m m a r y of feed ing st rategies in T a b l e 2 lists 14 s t ra teg ies / techn iques that the mothers in this s tudy u s e d to f eed their infants. T h e s u m m a r y sugges t s that the mothers in this s tudy u s e d a wide range of so l id food feed ing s t ra teg ies. A summary of mothers' solid food feeding strategies 1. offering the s a m e food ( repeatedly offering d is l iked foods) 2 . wai t ing (initially s topp ing o r g iv ing up) 3. swi tch ing (food types and/or brands) 4. mix ing (to alter taste or textures) 5 . adjust ing feed ing m a n a g e m e n t ( feeding routines) 6. soc ia l i z ing (family mea ls ) 7. mode l ing or mimick ing ( teaching infant how to eat) 8. engag ing (giving s o m e degree of control to the infant dur ing feeding) 9. p lay ing ( food play) 10. posi t ion ing ( feeding lying on back , restraining in c a r seat) 11. d istract ing, s n e a k i n g or camouf lag ing (using toys a s distracters dur ing feed ing to get food ea ten , mix ing rejected sol id foods with a c c e p t e d so l id foods to get food eaten) 12. pry ing (mouth open) , stuff ing/forcing (sol id food into mouth) 13. push ing (speci f ic f oods or feed ing transit ion pace) 14. hold ing b a c k (speci f ic foods) Table 2. A s u m m a r y of the sol id food feed ing s t rategies u s e d by mothers in this study. 88 RESULTS T h e s u m m a r y e x p a n d s our unders tand ing of the 'ways ' that mothers feed their infants and how they 'tailor* their feed ing s t ra teg ies in r e s p o n s e to their own percept ions, the infants' c u e s and the 'condi t ions ' within the infant f eed ing context . Th i s prov ides a better unders tand ing of the link be tween the p rocedures of infant feed ing (s t rategies/ techniques) , infant food a c c e p t a n c e and the feeding p r o c e s s . Further, an unders tanding of the determinants of infant f ood a c c e p t a n c e , in part icular, i ron fort i f ied c e r e a l s , e n h a n c e s our unders tand ing of determinants of dietary iron consumpt ion ove r t ime, f rom this sou rce . T h e s u m m a r y prov ides a useful list of potential feed ing strategies that cou ld be further desc r i bed a long a cont inuum of st rategies that poss ib ly promote or d i scou rage iron fortif ied infant ce rea l accep tance . C lear ly , s o m e feed ing s t rategies were less effective than other s t ra teg ies. T h e ava i lab le da ta sugges t that the 'way* the infant w a s fed m a y have in f luenced the s u b s e q u e n t a c c e p t a n c e of the so l id foods . 89 R E S U L T S 4.6. Gaining expertise T h e fourth t heme in the 3 -d imensional so l id food infant feed ing mode l is i l lustrated in Figure 14. T h e mode l now l inks the 4 t h e m e s - the feeding process, perceived infant food needs, ways of feeding, to the fourth t heme gaining expertise. T h e feed ing p r o c e s s a p p e a r s to be in f luenced by the mother 's infant feed ing know ledge , ski l ls and con f idence deve loped dur ing this transit ion p r o c e s s . T h u s , the mothers ' pe rsona l learning w a s labe led 'gain ing exper t ise ' . T h e f ive ma in c o m p o n e n t s to this t h e m e inc lude, f inding and us ing resou rces , be ing a first t ime mother and feel ing s c a r e d , s e e k i n g r e a s s u r a n c e , and learning through trial and error. 90 RESULTS Perceiving Infant Food Needs F o o d Preferences (taste-texture) Hunger Ways of Feeding Dynamic . switching . mixing . adjusting . engage etc. Static .repeatedly ottering dis- liked toods . waiting . distracting etc. ' 4 f J Readiness Deveiopmentai y < f f Figure 14. T h e 3 -d imens iona l infant so l id food feed ing mode l that l inks the fourth t h e m e 'gaining expertise' with the p rev ious three themes ; fhe feeding process, perceiving infant food needs and ways of feeding. T h e fourth t heme inc ludes 5 c o n c e p t s (f inding a n d us ing r e s o u r c e s , fee l ing s c a r e d , be ing a first t ime mother , seek ing r e a s s u r a n c e a n d learn ing through trial a n d error). 91 RESULTS 4.6.1. Finding and using resources T h e mothers used information f rom numerous resou rces , print a s wel l a s f rom verba l s o u r c e s , to gu ide their dec i s i ons with regards to infant so l id food feed ing . T h e three main print resources used by these mothers were the popular p ress s u c h a s books , m a g a z i n e s , and rec ipe books , pro fess iona l gu ide l ines a n d char ts , and/or pamph le ts p repared by baby food c o m p a n i e s and infant feed ing information on food packag ing . T h e verba l resources that were used were either f rom the pro fess iona l sec to r (public heal th nu rses , nutrit ionists, doctors , and commun i ty g roups, parent g roups and the nutrition hotl ine), or the mother 's soc ia l network (family, f r iends, and mothers ' g roups) . Of the m a n y resou rces c i ted, no mother c o m m e n t e d that information f rom the te lev is ion or radio had in f luenced their feed ing prac t ices . A s u m m a r y of the resources used by the part ic ipants is prov ided in T a b l e 3. Table 3. Resources used by study participants PRINT/PAPER Sources Popular Press 1. books (baby) 2. magazines 3. recipe books Professional 4. handouts of infant feeding guidelines and charts Commercial 5. pamphlets (prepared by infant food companies) 6. food packaging (including infant feeding information) V E R B A L Sources Professional 1. public health nurses 2. nutritionists 3. doctors 4. community groups 5. parent groups 6. nutrition hotlines Social Network 1. family 2. friends 3. mothers' groups 4. other experienced mothers 92 R E S U L T S T h e fol lowing quo tes give an e x a m p l e of the numerous resources mothers used in this s tudy as wel l a s what they found usefu l . In the first quote, the mother desc r i bes the impor tance of us ing a combina t ion of resou rces . Th i s mother s u g g e s t e d that 3 resources c o m b i n e d we re important, commun i t y nu rses , f r iends and read ing . T h e s e c o n d mother, a s in later quo tes , e x p r e s s e d c o n c e r n about hav ing to do s o m u c h g u e s s i n g and that it w a s difficult to f ind information. In addi t ion to these c o n c e r n s , the mother ref lected on the reality of be ing a 'first t ime m o m ' and be ing inexper ienced with feed ing bab ies . "What to Expect when You are Expecting" that's the big one...all the mothers have that one... My cousin gave me [a book] by Lousie Lambert...its about nutrition and children... there is just a whole bunch of them that I have a whole library of books and I just keep flipping through each one (1-264)... I probably do too much reading...that's the problem (1-294)... I'm actually learning a lot from another friend who has a ten month old and I see what she does and I really like...she is very liberal and I really like that and her baby is ten months and he eats all natural foods and he doesn't eat baby food any more and he is just a really he is like a solid baby you know strong solid what ever and ummm (1-1009)... I see the community groups that I have been going to and friends and books I mean all three combined but I would never suggest to any one just follow one you know what I me... Ya community health nurses, friends, and and reading and education (1-1435)". Books... My mother... Women who looks after him (9-892)... Pamphlets from doctor (9- 899)... Pamphlets...Baby Food Companies Send You... "What to Expect in the First Year" (9- 935)... Babysitter reads us a lot out of [a book by] Penelope Leach (9-940)... I find doctors aren't very helpful... or any of the doctors that I have talked to haven't been very helpful in terms of baby food questions... They don't seem to know the answers... transition formulas... ifs like 3 dollars cheaper a can. Which is a huge difference for us... I look at all the pamphlets that the baby food companies send you because. I find they're actually quite informative. Then we have that "What to Expect the First Years....[and a book by] Penelope Leach (9-935). [It's] Hard to find information (9-1028)... You just have to...figure out and guess...hope that it works (9-1062)... Nobody has any idea? I wish that there was somewhere saying ...5 months...[is] definitely too early for cottage cheese,...6 months is too early,... 7 months probably o'kay,...8 months is good...I wish I didn't have to do so much guessing (9-1080-1090)... I've never had any experience with babies...this is the first time I've ever had anything to do with babies (9-1095)". 93 R E S U L T S 4.6.2. Being a first time mother and feeling scared T h e mothers in this s tudy a p p e a r e d to be mov ing through a learning p r o c e s s f rom being a 'first t ime mother" who m a y be inexper ienced feed ing her infant so l id foods to becom ing exper ienced . F i ve mothers who desc r ibed t h e m s e l v e s as 'first t ime' mothers used the fol lowing exp ress ions to reflect their infant feed ing c o n c e r n s , " Y o u just don't know if you are do ing it right", "Every th ing is new" , " I feel l ike I don't know a t h i n g " , " Y o u ' r e not really su re what to do " , "It's like going into someth ing b l i nd ' , " C o n f us ing . . . I totally fee l l ike I don't know what I'm d o i n g " , " It's just s o diff icult ' , a n d " I a m unsu re . . . " . T h e s e e x p r e s s i o n s s e e m to reflect a d e g r e e of i nexper ience a n d poss ib ly a lack of con f idence poss ib ly due to the a b s e n c e of crit ical exper ience that is n e e d e d to unders tand how to f eed so l id foods dur ing the transit ion p r o c e s s . T h e fo l lowing quotes desc r i be c o m m o n fee l ings about be ing a 'first t ime' mother. Further, the third quote sugges t s that this mother 's inexper ience m a y have i nc reased her level of app rehens ion , s u c h a s fee l ing s c a r e d about the infant feed ing p r o c e s s itself. " Fee l ing s c a r e d " was a conce rn reported by seve ra l mothers! "Food in general seems to be a very big issue among moms. Being a first time mom it's like you know, going into something blind you [know]. You're not really totally sure what to do because you get all this advice and you get conflicting advice you know and stuff like that (5-675). "Confusing... I totally feel like I don't know what I'm doing (7-30)... Never been exposed to babies (7-794)... my biggest concern is that it is just so difficult [feeding solid foods] (7-577)... So that's just what I've found lacking because, you know, from the general information that I've got on how to feed a baby [he] doesn't... He doesn't do it. Like the books say. He hasn't read the book... So and I haven't been around babies a lot at all so he... [I am] guessing myself (7-626)". "I'm just learning... no idea what to give... its scary... Just starting out... we don't know...how much to give... what kind (12-806)". 94 R E S U L T S 4.6.3. Seeking reassurance T h e mothers in this s tudy d e s c r i b e d the impor tance of fee l ing ' r eassu red ' f rom external s o u r c e s about how they were feed ing their infants. T h e fol lowing quotes il lustrate how the mothers u s e d different resources for ' r e a s s u r a n c e ' . T h e s e mothers a p p e a r e d to be seek ing spec i f ic informat ion, poss ib ly in o rder to prov ide support and reassu rance . T h e information a p p e a r e d to be important b e c a u s e it p rov ided r e a s s u r a n c e that they were 'on track' with 'what they were s u p p o s e to be do ing ' , feed ing their infant. Further, a l though the mothers used print resou rces they s e e m e d to s e e k , in part icular, verba l r eassu rance f rom health ca re experts. "[Its] Just not knowing everything about your first baby is just not knowing right.. .everything is new and people can tell you this, people can tell you that the book can say one thing the nurse can say another...but when it is your first like you said I have all this knowledge in nutrition [but] I feel like I don't know a thing (1-1877)... Like for me I go to several drop-ins I might hear about nutrition a couple of times but then I get reassured o'kay that I am doing everything right you know (1-2801)... I need to feel reassured that I'm like. ..if I never went to these meetings and I never asked and never got support then I wouldn't be reassured and [that] I'm sort of on the track with what I'm suppose to be doing (1-2819)". "I have had some stuff sent to me from like, ummm Carnation and the formula people... And actually I found those books to be quite helpful (baby club, baby steps: Enfalac) and then some handouts from the group meetings (VPHD) ... And then I talked to my doctor about introducing some of the foods and some of the concerns I had as far as...how to introduce him to ...a more extensive range of foods and that. She gave me a sheet which, actually I kind of found it very reassuring because while a lot of the other things that you read tend to say umm 4-6 months to start off with and 6-9 months and stuff like that, they start at 6 months. . ..but it takes the later age so that you don't feel like you are missing something or you are being too slow with introducing foods (6-514)". S e v e r a l mothers c o m m e n t e d on the adv ice that they rece ived f rom different s o u r c e s . In part icular, learn ing f rom other mothers , espec ia l l y ' exper ienced ' mothers a p p e a r e d to be ex t remely usefu l . T h e s e mothers s e e m e d to be say ing that the adv i ce they rece ived or sought f rom other mothers w a s part icularly usefu l b e c a u s e it was pract ica l . T h e fo l lowing quotes a l so sugges t that the first t ime mother 's soc ia l network m a y be very important s i nce it m a y provide the 95 RESULTS n e e d e d opportuni t ies for exper ient ia l learn ing, in order to d i s c u s s exper iences and thus 'ga in so l id food feed ing exper t ise ' . T h e fol lowing mother u s e d a combinat ion of resou rces , one of wh ich w a s a n ' expe r ienced ' mother of 4 ch i ldren. T h i s mother, a s d id others mothers , ' r ece ived ' information f rom baby food c o m p a n i e s or publ ic health gu ide l ines but a l so 'sought ' information for her spec i f ic n e e d s . "My mother, and the woman who looks after him.. .she's got four kids... we ask her a lot of stuff and books, pamphlets that you get from the doctor... I look at all the pamphlets that the baby food companies send you because I find they're actually quite informative... (9-894)". "Always get unwanted advise (5-815))... Peoples experiences actually ...other moms... Friends who had babies (5-861)... Not necessarily first time mom's but should I say experienced moms tend to have really good ideas (5-869)... Helpful for moms to have a guideline ...I did get this one chart but it's very vague (5-895 910)... There was no warning about you know how to teach you child to chew things and stuff like that because I didn't find it didn't come automatic...it's not automatic (5-927)... I learnt that from a mom (giving Rice Krispies rather than Cheerios) (5-952)". "So I don't know try listening to other moms I guess I think is really good. Ya I think that is really key...like ya just little ideas you get from other moms what they do you know (10-563)... What to Expect in the First Year... Mother parent infant groups... nutrition hotline.... Your doctor ....list of... scheduling of what to do from 4 months. ..I've got it actually hanging on my fridge... (10-746) T h e mothers in this s tudy h a d sough t adv i ce (print a n d verbal) f rom heal th p ro fess iona ls . In the first quote , the mother sought 'expert ' adv i ce f rom health p ro fess iona ls , both in print and verba l form and had a s k e d ques t ions , however , the quote sugges ts that this mother w a s still unsure about how to feed her infant, espec ia l l y with regards to meat . T h e quote a lso reflects the mother 's inexper ience and that s h e w a s trying to f igure out how to feed her infant so l ids through us ing her print r e s o u r c e s a n d her doctor . P o s s i b l y , what this mother w a s s e e k i n g w a s r e a s s u r a n c e a n d pract ical infant feed ing informat ion, information wh ich d o e s not appea r to be prov ided f rom the resources that s h e had u s e d . 96 R E S U L T S "/ went to my four-month appointment with the doctor and she said... oh you should start vegetables too (8-61)... I got the Babies Best Chance from the Government, but it has it broken down into 3 month spans. Which is because kids vary of course but It would have been helpful to me if it said "for a big baby...do this" and I'm still like that right now because I am unsure as to what I should be doing when because my doctor said to me by twelve months he should be eating exactly what we eat, and I'm thinking that's only four months away. Not much time to get him doing that (8-354-367)... No it just says "Feed Solids"...at 6-9 months. It say's to feed solid foods 3-4 times per day and then it just gives a list of what you can try feeding him... It doesn't tell me how much of each thing he should have and I asked my doctor about the meat and she said umm that it was just my personal philosophy on meat. I mean we eat meat but I don't know maybe he needs it (8-375)... And then I got other baby books and everything's different (8-396)". A cr i t ique of the content of the informat ion rece ived by 'expert ' s o u r c e s is desc r i bed in the first quote. T h e te rm 'they 1 refers to heal th p ro fess iona ls . T h e mother c o m m e n t s not only on what ' they g ive you ' , s u c h a s start ing, s l ow p rogress ion , and goa ls by one yea r but a l so what 'they 1 don't "tell y o u " , s u c h a s " how to get there" . T h e mothers in this s tudy c i ted the n e e d for more 'spec i f ic informat ion' a n d u s e d p h r a s e s s u c h a s " g o with your inst incts. . . l is ten to your baby" and " s o m u c h information .. . cont rad ic t ing . . .go with how you f ee f to exp ress their expe r iences . T h e s e p h r a s e s sugges t the mother is 'ga in ing exper t ise ' and poss ib ly con f idence s i nce s h e appea rs to h a v e learned how to trust her own judgement . However , the ava i lab le da ta a l so sugges t that there a re g a p s in the so l id f o o d feed ing information prov ided for t h e s e mothers . "Because then some people say that by a year they should be eating sort of basically ...what [do]you do kinda thing (5-963)... [You need a] Map to get there .... like sure they tell you... start... then slowly get up to this... then they say by a year they should be eating what you are. But they don't say how to get there (5-983)... They say Oh don't give babies... The avoid things... I have a bit of a problem with them because umm I don't plan to deny having cookies or ice cream... (5-1016)". "Go with your instincts not books.../ mean use the books as guidance but I found, I would say go with the instincts, and listen to your baby rather than... Yah, use the book as a basis but then I think be open to... variations. You know, like, to listen to your baby and listen to yourself, and take care of the needs of both of you... It took awhile to trust (7-751)... To me I didn't have, I 97 R E S U L T S have never been exposed to babies...I didn't really know...signs to look for or, or what. So I felt really foreign to the whole thing (7-793)... 4.6.4. Learning through trial and error Learn ing to feed sol id foods w a s e x p r e s s e d by the mothers in this s tudy a s a p r o c e s s that took p lace ove r t ime. In gene ra l , all of the mothers a p p e a r e d to have ga ined expe r ience on how they fed sol id foods through 'trial and error 1 . T h e first quote i l lustrates a mother who a p p e a r e d to be inexper ienced and uncer ta in about what to do a n d thus m a y have been lack ing feed ing con f idence . T h e s e expe r i ences m a y have c rea ted a high level of frustration for this mother. T h e s e c o n d quote i l lustrates a mother that had b e e n feed ing sol id foods to her infant for s o m e t ime and appea red to be 'ga in ing exper t ise ' . T h e mother s tates it is " fun feed ing him now". Th i s s tatement s u g g e s t s that s h e has m o v e d a long a learn ing 'curve ' , a term co ined in the first quote, and has 'ga ined exper t ise ' . Interestingly, the s a m e ph rase sugges ts s h e m a y have expe r i enced a per iod of t ime w h e n it w a s not a s " fun feeding" her infant. "So I guess we're kind of going through a learning curve right now on how to [feed him]...So I still feel I'm kind of fumbling my way through. And hopefully he is getting enough nutrients (7-805)... They emphasize, you know, get a job, and business careers, and that's the training I took...School and even training outside of the home...look at a textbook... what do I do with a baby...I'm suppose to know... You're a mom NOW and you're suppose to know. I haven't the foggiest idea. And so for me, [that] has been the biggest problem all along.... There's not that tribal woman thing...my friends are working...their kids go to daycare (7-990). "Ifs just learning too because you are always so concerned that they are not getting enough food or what they're getting and part of the concern is you know if he is not eating you think oh you know something must be wrong or why isn't he eating that or he should be eating more. But I mean just have to realize that some days they don't. I'm starting to get more comfortable with some days he doesn't want to eat as much and some days he will want to eat more. But he seems and he doesn't like a lot of ...a lot of fruits but I think it's the pre-made fruits (10-343)... Some days I feel [he's] not eating enough... most of the time generally... I'm always concerned if he is getting enough fat and protein and it's really hard like I have to watch what he eats (10-431)... You just don't know how much liquid they are getting...hard to know... if I'm nursing enough...but I guess the food is compensating for the less nursing but I still get concerned that he is not getting enough proteins or whatever...[so I] read-up...[I am] reading it 98 RESULTS over and over... what to give... what I could give them and what I shouldn't give... obvious what you can't...[give them things they will] choke on...if they react [allergy]...[you] stop giving [it] (10- 532-560)... Ya that's the other thing like I don't follow the books... to the T. ..sort of like and they say you know when they are four months they should be eating this but he wasn't ready at four months he was ready two weeks later and that's fine. Like sometimes they are ready earlier, sometimes they are ready later and that didn't kinda worry me. I didn't let that, you let it worry you for a little bit and they you just have to step back and think.. .you know they're gonna let you know and I feel I am a lot more laid back with him now than I was 3 months ago and it's fun feeding him food now...(10-703)... The following quotes suggest that some mothers seemed very worried about their infant's slow weight gain. Further, these mothers seemed to perceive that they were more concerned than the health professionals from whom they had sought advice. It seems possible that these mothers were seeking reassurance on "how" to feed their infant. However, the response they received from 'experts' seemed to focus on the infant's weight rather than possibly the mothers underlying concerns, which could have been more about if she was feeding her infant solid foods appropriately. Interestingly, the mothers also did not appear to be fully comfortable with the feedback they received from these health professionals. In the second quote the mother describes a situation where her infant was refusing to eat solid foods. The response she received from the health professional consulted did not appear to address the mother's concerns. Consequently, this mother does not appear to have been reassured about her solid food feeding practices. [He] Stopped gaining weight around 6 months.. .And the doctor didn't seem too concerned ...he seems to be getting longer but just not heavier. ..that was bothering me (7- 836)... [I] guess for myself I would want like, more specific information ... like they did when he was a newborn (7-821) "... I was going to the mothers groups and asking about it, and they said don't worry about it, don't worry about it. And it then at six and a half months she hadn't gained any weight in close to two months.. She had stayed the same weight. And they were still saying don't worry, don't worry, she will get interested and we eventually she did, but...I was really worried about the weight gain (12-530)... Nothing. Not a pound. She was 16.2 up until about, she was weighed 99 RESULTS about two weeks ago. But the doctors say don't worry, it's o'kay. She's not skinny. She's not scrawny. She's a chubby little thing, so ya (12-550)... Well I know that the nurses were saying don't try umm until five months...don't try anything until 5 months [feeding solid foods], umm, but I don't know I just kind of, I wish there was more knowledge on what to feed your baby and when. Umm... I don't know. It was pretty, it it was pretty tough. I had a hard time when I was, every time I would go down to give her something to eat she wouldn't eat anything and the nurses were saying, oh don't worry about it, and yet she's not gaining any weight (12-621)... I would probably say that they are going to be getting so much information from everyone and a lot of it is gonna be contradicting. Umm and you just kind of have to go with how you feel (12-761)". T h e expe r i ence of be ing a 'first t ime mother 5 w a s a c o m m o n theme desc r i bed by the mothers in this s tudy. T h e mothers desc r i bed the exper ience of learning to feed their infants. T h e mothers a p p e a r e d to be mov ing a long a learn ing 'curve ' f rom be ing i nexpe r ienced to becoming e x p e r i e n c e d feed ing their infants so l id foods . T h e learning p r o c e s s a p p e a r e d to co inc ide with the mother 's level of certainty about 'how* to feed her infant a n d trust in her own judgement . M a n y of the mothers stated that r e a s s u r a n c e was important to t hem. R e a s s u r a n c e f rom health ca re p ro fess iona ls a p p e a r e d to be usefu l to mothers b e c a u s e it s e e m e d to help them 'tailor 1 their f eed ing s t ra teg ies acco rd ing to the r e s p o n s e s they rece ived . Interestingly, a l though the mothers rece ived and sought information f rom mult iple resources , pract ical information from 'exper ienced ' mothers , a p p e a r e d to a l so be highly va l ued . It s e e m s poss ib le that the concep ts desc r ibed in this sec t ion (f inding/using resou rces , be ing a first t ime mother and feel ing s c a r e d , seek ing r e a s s u r a n c e and learn ing though trial a n d error) in f luenced the mothers ' ' learning curve ' a n d thus if, or h o w qu ick ly the mother ga ined her infant so l id food feed ing 'exper t ise ' dur ing the liquid to so l id food transi t ion p r o c e s s . T h e type of r esou rces used (i.e., print ve rsus verbal) and the sou rce of the resource (i.e., p ro fess ion v e r s u s soc ia l networks) a p p e a r e d to in f luence the mother 's infant so l id food feed ing dec i s i ons . Further, the mothers a p p e a r e d to need information resources at spec i f i c s t ages of the feed ing p r o c e s s to meet their un ique indiv idual s i tuat ion (e.g., food re fusa l , s l o w weight ga in , texture diff icult ies, etc.) . T h e ava i lab le d a t a c lear ly sugges t that the mother 's so l id food feed ing 'capabil i ty" w a s de te rmined , to s o m e degree , by her level of 100 RESULTS feeding expertise. The fourth theme - gaining expertise attempts to capture 2 concepts potentially critical to how the mother feeds her infant solid foods. First, the level of expertise and second, the rate that the mother gains expertise. These concepts may be important conditions within the feeding process because they clearly have the potential to influence the mother's solid food feeding decisions. 4.7. Tailoring the transition process The fifth theme in the 3-dimensional solid food feeding model is illustrated in Figure 10 (page 52). The model links the 5 themes - the feeding process, perceiving infant food needs, ways of feeding, gaining expertise and the fifth theme tailoring the transition process. The 3 - dimensional solid food feeding model provides a conceptual framework to better understand the complex relationships among the categories and concepts discovered in this study. This figure reflects the interpretation of the interview transcript data and emphasizes the mothers' 'words' within the presented themes. Thus, Figure 10 illustrates the determinants that account for much of the mothers' behavior in this study within the context of the solid food feeding process. The fifth theme - tailoring the transition process was identified as the key determinant influencing the outcome of solid food feeding process, and thus was labeled as the 'core' theme. The mothers appeared to be tailoring {he'way that they fed their infants, in order to progress through a dietary transition. This dietary, transition is from the time the mother first introduces solid foods to her infant, to the time the infant accepts an appropriate range of solid foods in addition to their usual milk diet. 4.7.1. The causal-consequence model of infant solid food feeding Figure 15 provides a similar framework to Figure 10 but it is unique in that it shows the plausible relationships between the 5 themes to dietary adequacy (i.e., iron). The fifth theme evolved into the core theme because it explained best the potential variations in solid food acceptance and consumption patterns described by the mothers in this study. Thus, the core 101 RESULTS t heme tailoring the transition process is i l lustrated in F igure 15 a s 'centra l ' to the sol id food feed ing p r o c e s s a n d c o n s e q u e n c e s - dietary a d e q u a c y . T h e p laus ib le re lat ionships a m o n g the 5 t h e m e s were identi f ied, desc r i bed and d e v e l o p e d us ing the p rocedu res out l ined by the c a u s a l - c o n s e q u e n c e m o d e l (G laser , 1978) . T h e s e p rocedu res h a v e b e e n desc r i bed in the des ign a n d methods sec t ion . T h e co re t heme - tailoring the transition process w a s l inked to the other 4 t h e m e s (the feeding process, perceiving infant food needs, ways of feeding a n d gaining expertise), thus fulfil l ing its pr ime funct ion of integrating theory. 102 RESULTS Context The feeding process 1. The mother starting the feeding process and offering solid food 2. Sporadic versus routine cereal feeding 3. The reasons for introducing solids (advice, readiness, sleep) and food selection (food acceptance and allergy risk) Conditions 1. Type/brand of solid food 2. Infant age 3. Environment (work, infant feeding information and resources) Causal Conditions Mother factors: Perceptions of infant food needs 1. Readiness (allergies) 2. Food preferences 3. Hunger Infant factors: Food acceptance/ rejection responses to the solid food or feeding I Covariance -The individual variation and differences between mothers' ^diversity t Tailoring the transition process Consequences Dietary Adequacy . solid food acceptance :. solid food consumption pattern at Intervening Conditions (Contingent) 1 . Ways of feeding Dynamic/Static feeding strategies 2. Gaining Expertise finding and using resources being a first time mother and feeling scared seeking reassurance learning through trial and error Figure 15. The causal-consequence model of infant solid food feeding (adapted from Glaser, 1978), showing the plausible relationships between the five themes - the feeding process, perceiving infant food needs, ways of feeding, gaining expertise, tailoring the transition process and dietary adequacy. 103 RESULTS T h e co re theme has pract ical re levance to the day to day context of infant feed ing b e c a u s e it i n c reases our unders tand ing of not on ly how infants cou ld be fed sol id foods over t ime, but a l so why there are var iat ions a m o n g infant 's dietary consumpt ion patterns. A s F igure 15 i l lustrates, m a n y cond i t ions (i.e., the t ype of so l id f oods of fered, the infant 's a g e and the env i ronment (e.g. , work s c h e d u l e s , ava i lab le resources) within the infant feed ing context, eas i ly in f luence the co re t heme , thus mak ing the theme highly var iab le . Consequen t l y , the co re t heme c a n be e x a m i n e d a long a d imens ion f rom the mother ' tai loring', to the mother not ' tai loring' the sol id food transit ion p r o c e s s , in r e s p o n s e to her percept ions of her infant's food c u e s and r e s p o n s e s . T h u s , the range of behav io rs that the mothers use , or do not use , to feed their infants, represents the ' d imens ions ' of the fifth t heme - tailoring the transition process. T h e first t h e m e - fhe feeding process, identi f ies the potent ial re lat ionship be tween the mother start ing or offering sol id foods a n d the infant 's r e s p o n s e to what is offered (i.e., accep t ing or rejecting the food) . T h e interact ion (act ion-react ion) be tween the mother-infant pair and food is, therefore, the centra l focus of the t h e m e 'the feed ing p rocess ' . T h e link be tween the first and the fifth t heme c a n be further exp lo red by e m p h a s i z i n g the d imens iona l aspec t of the concep t ' tai loring'. Fo r examp le , if the mother offers so l id food but the infant rejects the food, the mother m a y then tai lor her feed ing strategy to try and ga in a c c e p t a n c e , or s h e m a y not tailor her st rategy a n d ins tead cont inue to offer the s a m e food in the s a m e way . T h u s , the concep t ' tai loring' represents the mothers ' ' w a y of adapt ing or not adapt ing the type of so l id foods and the feed ing strategy that s h e u s e d . T h e 'way* that the mother 'adapts ' c a n be cons ide red dynam ic (tailored) or static (not tai lored) with regards to promot ing a c c e p t a n c e of so l id foods , by the infant. T h e first t heme - the feeding process p rov ides the context within wh ich the many condi t ions exist, that eas i ly inf luence if, or how the mother ' tai lors the transit ion p r o c e s s ' . C lear ly , food a c c e p t a n c e or rejection by the infant dur ing ' the feed ing p rocess ' is a pr imary factor that potential ly ' c a u s e s ' the mother to beg in ' tai loring' her infant f eed ing st rategy. T h e s e c o n d t heme - perceiving infant food needs identi f ies the potential relat ionship be tween the mother 's percept ions of her infant 's food n e e d s and their inf luence on her s u b s e q u e n t so l id food feed ing behav io rs . T h u s , this t heme is a l so cons ide red a s key in 104 RESULTS potential ly c a u s i n g the mother to beg in ' tai loring the transit ion p rocess ' . T h e mother 's percept ion of 4 key food c u e s a p p e a r e d to strongly in f luence the mothers ' feeding dec i s ions . T h e c u e s inc luded infant deve lopmen ta l read iness , food taste and texture pre ferences , hunger and al lergy risk. T h e link be tween the s e c o n d and the fifth t h e m e c a n be further exp lo red by emphas i z i ng the d imens iona l a s p e c t of the concep t ' tai lor ing'. T h e mothers ' percept ions of their infants' food needs a p p e a r e d to c lear ly inf luence their so l id food feed ing strategies - ' tailoring'. Fo r examp le , the mother who recogn ized that the infant w a s not accep t ing the sol id food b e c a u s e he /she m a y not have b e e n hungry cou ld 'tailor" her next so l id food mea l t ime accord ing to her infant's hunger c u e s s o that the food m a y then be a c c e p t e d better by the infant. T h e mother w h o recogn ized that her infant w a s hungry at spec i f ic t imes of the d a y cou ld , therefore, respond by adapt ing her feed ing s c h e d u l e acco rd ing to these c u e s . In this context , this mother a p p e a r e d to have been 'tai loring' her feed ing st rategy by l inking her percept ions of her infant's food n e e d s (cues) to the infant feed ing techn iques that s h e w a s us ing , in order to respond accord ing ly . T h e mothers that did not pe rce ive a n y infant food c u e s (e.g. , hunger c u e s ) , or misinterpreted food c u e s (e.g., food p re fe rences) , m a y not have been ab le to effect ively 'tailor 1 their feeding s t rategies to meet their infant 's ' f ood n e e d s , in the s a m e w a y a s mothers w h o we re ab le to recogn ize t h e s e c u e s . T h u s , the mother 's percept ions of her infant's food n e e d s a p p e a r e d to be a ' causa l condi t ion ' inf luencing if, or how the mother ' ta i lored' her so l id food feed ing response . T h e third t h e m e - ways of feeding i l lustrated in F igure 15 identif ies the potent ial re lat ionship be tween the mother 's feed ing s t ra teg ies and the infant's a c c e p t a n c e of sol id foods (solid food consumpt ion) . A wide range of infant feed ing techn iques w a s d i scove red f rom the mothers ' descr ip t ions of how they fed their infant dur ing the feed ing p r o c e s s . S o m e of the feed ing techn iques s e e m e d to be better at promot ing sol id food a c c e p t a n c e than other techn iques (i.e., mix ing a n d swi tch ing c o m p a r e d to wait ing or repeatedly offering prev ious ly rejected foods) . T h e concep t 'adapt ing ' is the key aspec t of the third t heme b e c a u s e , l ike ' tai loring', it e m p h a s i z e s that sol id food feed ing is a p r o c e s s over t ime and that the mother 's behav io rs a re in f luenced by the rapidly chang ing condi t ions within the sol id food feed ing context. Howeve r , the mother 's 'way ' of feed ing so l id foods is a 'cont ingent ' factor that a p p e a r s to directly 105 RESULTS affect the co re theme. In order for the mother to 'tailor 1 or 'adapt ' her feed ing behav io rs s h e must use a feed ing strategy(s) or technique(s) . There fo re , the mother 's so l id food feed ing behav iors are cont ingent or condi t ional to the indiv idual s t ra tegies or techn iques that s h e u s e s . T h e link be tween the third and the fifth t heme c a n be further exp lored by emphas i z i ng the d imens iona l a s p e c t of the concep t ' tai lor ing'. It s e e m s poss ib le that the mother m a y c h o o s e to tailor her feed ing strategy by adapt ing her feed ing technique(s) to promote the consumpt ion of the sol id foods that s h e is offering dur ing the t ransi t ion f rom a n exc lus ive l iquid diet to a m ixed liquid and so l id food diet. Fo r examp le , posi t ioning the infant o n their back to feed so l ids a p p e a r e d to b e effect ive for o n e mother w h e n s h e w a s first start ing so l id foods . Soc ia l i z i ng with the infant dur ing mea l t ime and a l lowing the infant to have s o m e control over the feed ing exper ience , or ' engag ing ' the infant whi le feed ing a p p e a r e d to be effective s t rategies for other mothers . Howeve r , s o m e mothers m a y not have recogn ized a n y relat ionship be tween the feeding st rategy that they were us ing and the amoun t of so l id food their infant c o n s u m e d . A s a result, t hese mothers m a y not 'tailor" their infant feed ing technique(s) . Consequen t l y , the transit ion p r o c e s s for indiv idual infants w a s highly var iab le and this variabi l i ty m a y be exp la ined , in part, by if, or how the indiv idual mothers were 'tai loring the transit ion p rocess ' . T h e fourth t heme - gaining expertise i l lustrated in F igure 15 identif ies the potential relat ionship be tween the indiv idual mother 's learn ing to feed her infant and her capabi l i ty to 'tailor 1 the ' w a y s h e fed her infant dur ing the transit ion p r o c e s s . For examp le , a 'first t ime' , poss ib ly inexper ienced mother , a p p e a r e d to p rog ress a l o n g a ' learn ing curve" where s h e learned to f eed her infant so l id foods . Th i s p r o c e s s a p p e a r e d , for s o m e mothers , to be through trial and error expe r iences , a n d rece iv ing or s e e k i n g r e a s s u r a n c e f rom the ava i lab le infant feed ing resources that they u s e d . T h e expe r i ences that the mother encoun te red dur ing the feed ing p r o c e s s and the resources that s h e used potential ly p romoted her learning to b e c o m e an expe r i enced feeder . T h e ava i lab le da ta sugges t that s o m e of the resou rces (Pro fess iona l Gu ide l i nes and commerc ia l pamphle ts a n d food packag ing information) that were ava i lab le to the mothers , appea red to focus on what type of so l id foods to feed an infant at spec i f i c a g e s . Interestingly, most of the resources used by the mothers , in this s tudy, d id not a p p e a r to focus on descr ib ing the pract ica l , day to day, 106 RESULTS aspec t s of how to feed an infant so l id foods , dur ing the transit ion p rocess when the infant is learning to accep t a range of different so l id foods . T h e link be tween the fourth and fifth t heme c a n a lso be further explored by e m p h a s i z i n g the d imens iona l a s p e c t of the concep t ' tai loring'. T h e mother cou ld potential ly 'tailor' her feed ing strategies and techn iques , however , her ac tua l ' tai loring' capabi l i ty appea red to be c lear ly in f luenced by her level of feed ing 'exper t ise ' . Fo r 'first t ime' mothers, it s e e m s poss ib le that ear ly o n in the feed ing p r o c e s s , w h e n the mother first in t roduces so l id foods , the mother m a y be inexper ienced a n d , therefore, l ess sk i l led and conf ident at ' tai loring' her feed ing s t ra teg ies. T h e 'way 1 that the mother ' tai lors' her feed ing techn iques may , therefore, be less resourcefu l ear l ier than later on in the feed ing p r o c e s s w h e n the mother has 'ga ined ' more exper ience a n d has deve loped more feed ing ski l ls and con f idence . Fo r examp le , the inexper ienced mother , ear ly in the transit ion p r o c e s s , m a y not have learned yet w h e n in the day to feed her infant so l id foods . In contrast , with t ime and expe r i ence the mother m a y learn w h e n in the day the infant is mos t hungry a n d then 'tailor' her feed ing strategy by adjust ing her feed ing schedu le to be more c lose ly a l igned with w h e n , in the day , her infant is hungry. T h u s , it s e e m s clear ly poss ib le that the mother 's capabi l i ty to effect ively 'tailor' her so l id food feed ing strategies dur ing the transi t ion p r o c e s s is re lated to her so l id food feed ing exper ience(s ) and the level of 'exper t ise ' that s h e ga ins over t ime. T h e concep t 'ga in ing ' , is a key a s p e c t of the fourth theme b e c a u s e like ' tai loring' it e m p h a s i z e s that the mother ' s abil i ty to learn to f e e d so l id f oods is a p r o c e s s ove r t ime. It a l s o s e e m s poss ib le that the mother 's level of feed ing 'exper t ise ' (capability) a s wel l a s the s p e e d at wh ich the mother ' ga ins ' exper t ise in f luenced her ' tai loring' st rategies. Both factors, the 'expert ise ' itself a n d the s p e e d at wh ich the 'exper t ise ' is ga ined , m a y expla in s o m e of the variabil i ty a m o n g the so l id food consumpt ion pat terns of the infants in this study. A s indicated in F igure 14 the t h e m e 'ga in ing exper t ise ' w a s labe led a s a rapidly chang ing 'condi t ion ' within the sol id food feed ing context . 107 RESULTS 4.7.2. Dietary intake patterns T h e impor tance of d ietary iron intake for the rapidly growing infant dur ing the s e c o n d s ix months of life is wel l d o c u m e n t e d . There fo re , the consumpt ion of iron conta in ing sol id foods is of part icularly interest, dur ing the l iquid to so l id food transit ion p r o c e s s that usual ly occu rs be tween 4 - 9 months of age . Fo r that r eason , the ce rea l feed ing pract ices dur ing this per iod were identi f ied. A legend w a s d e v e l o p e d f rom the interview da ta (Table 4) and w a s used to identify a n d graphica l ly represent the s o u r c e s of so l id foods that the mothers fed their infants at different a g e s consis tent ly a c r o s s the part ic ipants. W h e r e poss ib le , the quanti ty of so l id food that w a s fed a n d the feed ing techn iques (i.e. 'offering' s ing le gra in c e r e a l s o r 'offering' ce rea l mix tures etc.) that were u s e d were desc r i bed . T h e 3 ar rows in the legend s h o w the a g e w h e n the mother fed s ing le grain ce rea ls , ce rea l comb ina t ions , or fruits or vege tab les . Th i r teen i tems and var iat ions of feed ing were identif ied a n d a re l isted in the legend in T a b l e 4. S i x var iat ions perta in ing to iron fortified infant ce rea l feed ing were desc r i bed by the mothers a n d inc luded in the l egend (numbers 1 through 6). T h e first pattern w a s labe led a s r ice ce rea l , to reflect the exc lus i ve feed ing of infant r ice ce rea l (1). T h e s e c o n d pattern (2) refers to the feed ing of a var iety of other s ing le grain ce rea l s . T h e sol id ar row ( ^ ) w a s u s e d to indicate that a mother a p p e a r e d to be feed ing s ing le gra in ce rea l var iet ies only at that age . T h e third pattern (3) reflects a mother 's feed ing with m ixed grain ce rea l s . T h e fourth pattern (4) represents swi tch ing c o m m e r c i a l ce rea l b rands , s u c h a s f rom H e i n z to Ge rbe r . T h e fifth pattern (5) refers to the use of c o m m e r c i a l ce rea l p remixed with fruits or vege tab les . T h e last ce rea l feed ing pattern (6) represents 'mix ing ' ce rea ls with fruits and/or vege tab les by the mother. T h e b roken ar row ( — — — • ) , i l lustrated in the l egend w a s u s e d to ind icate that a mother a p p e a r e d to have c h a n g e d f rom feed ing the s ing le grain ce rea l var iet ies to feed ing m ixed ce rea l var iet ies and food comb ina t ion mix tures, at the age ind icated. Fou r var iat ions of feed ing fruit and vege tab les were identi f ied f rom the transcr ipts (numbers 7 through 10); t hese we re s ing le fruits or vege tab les , or m ixed fruits or vege tab les . Subca tego r i es were u s e d to indicate if the fruit or vege tab le w a s pu reed (a) or m a s h e d (b). 108 R E S U L T S Broken arrows ( — . . ^ ) , in the individual graphs, indicate when a mother appeared to start feeding fruits and vegetables and corresponds, on the graph, with the approximate quantity of food fed at the different ages indicated. The finger food snacks that were fed to infants included regular breakfast cereals, cheese, crackers, toast and fruit, and are identified as sf. The dairy food snacks fed to infants included cheese and/or yogurt, and are identified as =d. Two variations of meat feeding, feeding with single meats and/or meats mixed with fruit or vegetables were identified and divided into 6 subcategories: homemade meat (a1), commercially prepared meat (a2), 'trying' to introduce meat (b), 'routine' meat feeding (c), pureed consistency (d) or chunky consistency (e). The range of solid foods fed to infants between 3 - 9 months of age. 1 Rice Cereal 2 Single Grain Cereals (Oat/Barley/Wheat...) 3 Mixed Grain Cereals (Oat and Barley) 4 Switching Cereal Brands (Heinz/Mead/Gerber...) 5 Grain Cereals (with added Fruit or Vegetables) 6 Cereals (1/2/3/5) Mixed with fruits or vegetables 7 Single Fruits 8 Single Vegetables 9 Mixed Fruits 10 Mixed Vegetables (a=pureed/b=mashed = S N A C K S f (Finger F o o d s ; e.g. regular breakfast cereals, cheese pieces, crackers, toast fruit pieces and d (Dairy snacks; e.g. cheese and/or yogurt) Single Meats -v- Meats Mixed with Fruit or Vegetables (a1 homemade; a2 commercial ly prepared; b trying to feed meat; c routinely feeding meat; d pureed; e chunky) Table 4. The legend identifies the variety of solid foods in the transition graphs that the infants were fed at different ages. 109 RESULTS Table 4 was used as the framework to identify and describe the feeding and transition process, graphically. The 12 transition graphs (Appendix G) were developed using the list of foods in the legend above. The individual infant's approximate consumption patterns for iron fortified infant cereal were explored in the most detail because of its importance as a source of dietary iron during the transition period. The underlying assumption is that between the age of 3 - 9 months the most common source of dietary iron from solid foods would most probably be from iron fortified infant cereal. Therefore, the transition graphs for the individual infants were sorted into similar/different groups according to the quantity of cereal consumed per day at specific ages. The within case analysis was based on the mother's self-report of her present and past feeding practices with respect to the approximate quantities of infant cereal and other solid foods the infant consumed. The transition graphs identified the following solid food feeding practices of the individual infants. As would be expected, the age of introduction of iron fortified cereals differed among the infants. All of the infants in this study were introduced to iron fortified infant cereal between 3 - 5 1/2 months of age. Most of the mothers started with rice cereal and progressed from rice to other single grain cereals, such as oats and barley. The mothers then progressed to mixed varieties such as mixed grains or grains with added fruits or vegetables. The transition graphs of the individual infants also identified the mother's solid food feeding practices with regards to the 'routine' feeding of iron fortified infant cereals and meats. As the graphs illustrate, the feeding practices differed among the infants with respect to the time it took them to routinely accept cereal. Two mothers took about 2 weeks, or less (graph number 9 and 5), Two mothers took about 1 month (graph number 1 and 6). Three mothers took about 11/2 months (graph number 2, 8 and 12). Two mothers took about 2 months (graph number 4 and10). Interestingly, 1 mother took about 3 months (graph number 7) and 2 infants (graph number 11 and 3) never accepted cereal in any substantial quantity. The time it took each mother to establish 'routine' feeding of cereal appeared to be closely related to the infant's acceptance of the cereal. The available data suggest that the infant's acceptance of solid food appeared to be closely related to, or influenced by, the core theme - tailoring the transition process. 110 RESULTS T h e feed ing prac t ices a l so di f fered a m o n g the mothers with respect to the quanti ty of ce rea l c o n s u m e d . At the t ime of the interview with the mother, most (10/12) of the infants be tween the a g e of 7 - < 9 months c o n s u m e d approx imate ly < 3 tab lespoons to > 1 cup of dry ce rea l per day . T h e remain ing 2 infants c o n s u m e d about 1/3 c u p dry - 1 c u p wet ce rea l per day , at 9 months of a g e . Wi th in 1 month after introducing ce rea l s , most of the mothers (7/12) in t roduced either vege tab les or fruit, or both to their infants. T h e remain ing 5 mothers in t roduced vege tab les later (between 1 a n d 4 months after ce rea l introduction). S ing le fruits or vege tab les were fed to the infants first, and then a s the infant got o lder, s o m e mothers fed m ixed var iet ies. S e v e r a l mothers intent ional ly fed al ternat ing co lo rs of fruits or vege tab les (e.g. g reen a n d orange) , a s wel l a s a var iety of different f ru i t /vegetables of the s a m e color (i.e. g reen b e a n s , p e a s , a n d sp inach ) in o rder to g i ve var iety in the diet. A s i l lustrated in the g raphs , on ly 1, 9 month old infant, w a s fed meat on a 'routine' bas is (graph number 5). S e v e n infants be tween 7 and 9 months of a g e we re 'trying' meats but their mother had not yet p rog ressed to 'routine' meat feed ing . T h e remain ing 4 infants, who were be tween 7 and 8 months of a g e , had not been g iven any meat products . Fo r t hose who did feed meat , it w a s usual ly fed mixed in a combina t ion with a fruit or vege tab le (i.e. in a combina t ion of 1:4 meat with vegetab les) in order to i nc rease a c c e p t a n c e . T h e transi t ion g raphs w e r e sor ted into 3 g roups acco rd ing to the approx imate quanti ty of ce rea l the infant c o n s u m e d . T h e 3 g roups identif ied reflect low, med ium and high ce rea l consumpt ion leve ls (F igure 17). A high cerea l consumpt ion group (graph numbers 5, 8 and 9) was identified for 3 infants who we re 7 Vi, 8 Vz a n d 9 months of a g e . T h e mothers reported that their infants c o n s u m e d approx imate ly 1/3 cup ( -8 tbsp.) - 1 cup of dry iron fortified infant ce rea l per day , f rom 6 months of a g e to their present a g e . T h e transit ion g raphs of the 'h igh' ce rea l consumpt ion g roup of infants sugges t s that the mother 's sol id food feeding s t ra teg ies / techn iques over t ime a p p e a r e d to promote a c c e p t a n c e of a h igh quant i ty of infant ce rea l . Further, a c c e p t a n c e of infant ce rea l at a h igher quanti ty con t inued for a m u c h longer durat ion than the other 2 g roups (med ium and low consumpt ion) . T h e transit ion g raphs for this group of infants appea rs c lear ly different form the other 2 g roups . i l l RESULTS A med ium cerea l consumpt ion group (graph numbers 1, 2, 4, 6, 7 , 1 0 and 12) was identified for 7 of the infants w h o were be tween 7 - 9 months of a g e and reflects the consumpt ion of about < 4 tab lespoons of dry ce rea l per day at 6 months of a g e . F i ve of the infants in this group rece ived approx imate ly 1/4 cup ( -5 tab lespoons) of dry ce rea l per day be tween 7 - 8 months of age . A l though one infant (graph number 1) c o n s u m e d about 1/2 cup of dry cerea l per day at 71 /2 months of age , the amoun t c o n s u m e d at 6 months w a s more reflective of the m e d i u m consumpt ion g roup than the high consumpt ion g roup. T h e da ta ava i lab le for one 9-month-old infant (number 2) w a s l imited be tween the 6 - 8 month per iod and therefore the g raph ind icates a quest ion mark for the quant i ty of ce rea l c o n s u m e d dur ing that t ime. However , the interview da ta sugges t that the ear l ier transit ion p r o c e s s w a s ref lect ive of a s lower a c c e p t a n c e cu rve , compat ib le with the m e d i u m rather than the high ce rea l consumpt ion group. T w o mothers in the m e d i u m ce rea l c o n s u m p t i o n g roup e x p r e s s e d c o n c e r n about their infant's weight ga in (graph numbers 7 and 12). T h e ce rea l consumpt ion pattern in g raph 7 ind icates that the infant w a s in t roduced to so l id food before 4 months of a g e and then not 'routinely' fed ce rea l until 6 months of age . Th i s infant a p p e a r e d to have been c o n s u m i n g about 4 t ab lespoons of dry ce rea l per day be tween 6 a n d 7 months of age . T h e mother 's feed ing strategy, s h o w n by the so l id arrow, ind icates that th is mother u s e d only the first of the s ix ce rea l feed ing var iat ions l isted on the legend . Th i s infant w a s fo rmula fed from 10 d a y s after birth. T h e ce rea l consumpt ion pattern in graph 12 ind icates that this infant w a s introduced to so l id food at about 4 months of a g e , yet didn't appea r to accep t a larger quanti ty until about 6 months of age . A c c e p t a n c e a p p e a r e d to i nc rease w h e n the mother first sw i tched ce rea l b rands at 5 months , and sw i tched to feed ing p rem ixed ce rea l s with a d d e d fruit or vege tab les at 6 months . T h e infant in graph 12 w a s breast fed exc lus ive ly to 1 month of a g e a n d then int roduced to 2-4 o u n c e s of formula per day f rom 1 - 7 months of a g e . T h e a c c e p t a n c e of ce rea l by infants in the m e d i u m consumpt ion group a p p e a r e d to take longer, in genera l , than in the high ce rea l consump t i on group, that is, the transit ion g raphs for this group of infants reflect the s lower p a c e of infant ce rea l a c c e p t a n c e . T h e transit ion pattern for this group of infants a l s o a p p e a r s c lear ly different f rom the high and low ce rea l consumpt ion groups. 112 RESULTS A low cerea l consumpt ion group was identified for 2 (graph numbers 3 and 11) infants who were 7 and 8 months of a g e . T h e low ce rea l consumpt ion pattern reflects the consumpt ion of approx imate ly 3 t ab lespoons or less , of dry ce rea l per day , f rom the a g e of introduction to the infant's present a g e . T h e transit ion g raphs of the ' low' ce rea l consumpt ion group sugges ts that these mothers ' so l id food feed ing s t ra teg ies / techn iques o v e r t i m e appea red to not promote a c c e p t a n c e of infant ce rea l w h e n the ce rea l w a s int roduced at 4 and 5 months , nor throughout the next 3 months . O n e mother a p p e a r e d to u s e s ing le grain ce rea ls until approx imate ly 6 months and then sw i t ched to ce rea ls m ixed with fruit or vege tab les (i.e. s h e u s e d 2 of the 6 cerea l var iat ions l isted in the legend) . Nei ther s t rategy i nc reased ce rea l a c c e p t a n c e . Howeve r , at 7 months , this infant rece ived 4 var iat ions of the fruits and vege tab les that a re l isted o n the legend a s numbers 7, 8, 9, a n d 10. T h e infant w a s desc r i bed a s readily accept ing of t hese sol id foods . T h e other mother in this group used s ing le grain ce rea l s , other than rice ce rea l . T h e avai lable data are unc lear a s to whether or not s h e used other cerea l feeding strategies listed in the legend. However , the infant appeared to accept a generous amount of vegetables e a c h day by 5 months of age . Interestingly, both of these mothers appea r to be feeding a larger quantity of fruits and/or vegetab les than infant cerea l per day. T h e 7 month o ld infant (graph 3) w a s exc lus ive ly breast- fed until 6 months , a n d then swi tched to 'm i xed ' feed ing with low iron formula. T h e other infant (graph 11) w a s exc lus i ve ly breast- fed to 8 months . T h e ava i lab le da ta sugges t that t hese 2 infants m a y not have a c c e p t e d adequa te quant i t ies of iron conta in ing ce rea ls for an adequa te durat ion. T h e mothers ' l iquid (milk and formula) feed ing pract ices over t ime were a l so identif ied b e c a u s e the milk feed ing prac t ices m a y be c l ose l y l inked to subsequen t so l id food feed ing pract ices dur ing the transit ion p r o c e s s . Fo r e x a m p l e , the f requency a n d quanti ty of milk or formula fed to the infant dur ing the day cou ld in f luence the quantity of so l id food that the infant will accep t d u e to sat iety. In genera l , mothers p rog ressed f rom exc lus ive breast - feeding to mixed feeding ( feeding both h u m a n milk and formula) , or fo rmu la feed ing. Th ree exc lus ive ly breast- feed ing mothers p rog ressed to exc lus ive ly f eed infant formula . A s wou ld be expec ted , the liquid feeding pat terns var ied with regards to durat ion a m o n g the s tudy part ic ipants. 113 RESULTS F i g u r e 16 . T h e type of milk fed to 12 infants f rom birth. S i n c e the iron content of infant fo rmu las var ies the type of formula used w a s reco rded , where poss ib le . At birth, al l of the infants were breast - fed . At the t ime of the interview, 4 mothers were breast - feed ing their infants of 7, 7 Vz, 8 and 9 months of a g e without feed ing any fo rmula . S i x mothers breast - fed exc lus ive ly for a shorter durat ion, and then swi tched their infant to m ixed breast and fo rmu la feed ing at <1, 2, 4 or 5 months of a g e . Of these 6 mothers, 2 then swi tched to exc lus ive fo rmu la feed ing w h e n the infant w a s 6 M> a n d 7 months of a g e . T w o mothers fed formula , start ing at 10 d a y s and 1 month after birth. O n e mother in this study fed low-iron fo rmula be tween 5 and 7 months after exc lus ive ly b reas t - feed ing her infant to 4 months of age . T h e other formula feed ing mother didn't state the iron content of the formula . Of the 12 mothers in this study, 7 were feed ing var ious quant i t ies of iron fortif ied fo rmu la to their infants. 114 RESULTS 4.8. Questionnaire Results Five ques t ions we re d e v e l o p e d in sec t ion A of the quest ionnai re to identify the mothers ' l iquid feed ing prac t ices (Sec t ion A ) . A l l of the mothers in this s tudy breast fed at birth. At the t ime of the interview, 5/9 mothers we re still b reast - feed ing. M o s t mothers s tated that they had rep laced or supp lemen ted their breast milk feed ing with infant fo rmula . Unfortunately, the quest ion cou ld have b e e n interpreted differently by the mothers . Mothers ' retrospect ive r esponses cou ld have b e e n y e s to both supp lementa t ion and rep lacement of breast - feeding with infant formula. Mos t mothers (8/9) s tated that breast - feed ing w a s not supp lemen ted or rep laced with cow, goat, or soy-mi lk . O n e mother m isunders tood cows ' milk for infant formula. Of the 5 mothers breast - feeding their infant, 1 mother breast fed o n c e per day , 1 mother 3 t imes per day , 1 mother 4 t imes per day , 1 mother 5 t imes per day , and the last mother breast fed 8 t imes per day . Of the 7 mothers w h o repor ted giving infant fo rmula to their infant, only 1 reported the f requency they fed their infant, wh ich w a s 4-5 t imes per day. T h e mothers reported a range of fo rmula feed ing prac t ices f rom feed ing 8-10 o u n c e s of fo rmula o n c e per week to feed ing 24 o u n c e s per day . T h e data ob ta ined f rom these 5 quest ions cap tu red da ta at one t ime point. T h e data that w a s gathered in the s p r e a d s h e e t format w a s more c o m p r e h e n s i v e than the s ing le r e s p o n s e format desc r ibed a b o v e . T h e s p r e a d s h e e t w a s more effect ive at obta in ing greater detai l , thus potential ly giv ing a better unders tand ing of the mothers ' l iquid feed ing pract ices over t ime. T h r e e s p r e a d s h e e t s we re d e v e l o p e d for the quest ionna i re to identify the types, b rands and amoun ts of l iquids, c e r e a l s , and other so l id foods that mothers fed their infants over t ime. T h e intent of the first s p r e a d s h e e t in the quest ionna i re w a s to attempt to capture l iquid feed ing pract ices ove r t ime a n d identify how mothers ' l iquid feed ing prac t ices p rog ressed a s the infant a g e d . T h e da ta f rom the s p r e a d s h e e t format a p p e a r e d promis ing b e c a u s e it w a s quick, e a s y and prov ided detai l o n what type a n d amoun t of milk w a s g i ven at different a g e s . H o w e v e r , further rev is ions are n e e d e d in order to elicit cons is tent da ta ( f requency of f eeds and the quantity). Al l of 115 RESULTS the mothers reported that they breast fed their infant in the hospi ta l . On l y 4 mothers reported the f requency that they b reas t fed their infant over t ime. O n e mother started feed ing 11 t imes per d a y and then d e c r e a s e d f requency to 7 or 8 t imes per d a y at 4 months . At 6 months, the mother breast fed her infant 6 t imes per day and then d e c r e a s e d f requency to 4 or 5 t imes per day by 7 months . T w o other mothers fo l lowed s imi lar patterns of breast - feeding 8 t imes per day to about 4 months and then d e c r e a s e d f requency to 6 t imes per day at about 5 months, and 3 t imes per day at 7 months . In contrast , 1 mother breast fed her infant 8 t imes per day cons is tent ly f rom 1 to 7 months . T h e mothers w h o fed fo rmula did not report the f requency. Four mothers a l so d id not report the quant i ty of f o rmu la they u s e d . F o r the two mothers w h o reported the quant i ty of fo rmula they u s e d , 1 mother fed 1125 milli l iters per d a y f rom 1 to 6 months and the other fed 750 milli l iters per d a y to 7 months of age . N o mother repor ted us ing c o w s ' milk (whole, 1 %, or sk im) , soy-mi lk , or goats milk. F ive mothers reported us ing iron-fortified fo rmula . E a c h mother used infant fo rmu la at different t ime points that co r respond c lose ly to the mothers ' wean ing pract ices. O n e mother u s e d iron-fortified fo rmu la for 1 month when her infant w a s 6 months of age . Another mother u s e d this fo rmula for 2 months w h e n her infant w a s 6 and 7 months of age . T w o mothers reported us ing this fo rmu la type for 4 months , one w h e n the infant w a s 5 to 8 months , the other w h e n the infant w a s 6 to 9 months of a g e , respect ive ly . T h e last mother reported us ing fo rmu la for 7 months w h e n her infant w a s 1 to 7 months of age . F o u r mothers repor ted feed ing low iron fo rmu la . O n e mother fed low iron fortif ied fo rmu la for 1 month w h e n the infant w a s 1 month o ld . T w o mothers fed this formula for 2 months . O n e w h e n the infant w a s 3 a n d 4 months of a g e and the other w h e n the infant was 2 and 3 months of age . Interestingly, o n e mother started feed ing low iron fo rmula at 8 months after swi tch ing f rom iron fortified fo rmula . J u i c e w a s introduced and fed to 1 infant at 4 months , 2 infants at 5 months , 4 infants at 6 months a n d 3 infants at 7 months of a g e , respect ive ly . Twe lve ques t ions we re deve loped in sec t ion B of the quest ionnai re to identify mothers ' iron fortified infant ce rea l feed ing prac t ices in o rder to unders tand better how these prac t ices ove r t ime m a y potential ly in f luence infant iron status. A l l mothers s tated that their infant ate ce rea l . 116 RESULTS W h e n first start ing infant ce rea l m a n y mothers (5/9) u s e d breast milk to prepare the ce rea l . O n e third of mothers u s e d fo rmu la a n d only one mother u s e d water to prepare the cerea l w h e n they first started to mix l iquids with the infant ce rea l . Howeve r , at the t ime of the interview, 5 mothers were us ing fo rmula , 3 mothers we re us ing water and a few were us ing juice or yogurt. Interestingly, one mother u s e d 4 different cerea l preparat ion methods . Mos t of the mothers (8/9) s tated that their infants ate al l the ce rea l that w a s p repa red . M a n y mothers (5/9) s tated they 'a lmost a lways ' p repared the s a m e quanti ty of ce rea l e a c h t ime they fed their infants. A few mothers (2/9) stated that they ' some t imes ' p repared the s a m e quantity e a c h t ime they fed their infant. Interestingly, m a n y mothers (5/9) stated that they 'a lways ' , 'a lmost a lways ' or ' somet imes ' p repared more ce rea l if their infant w a s hungry. M a n y mothers (7/9) stated that they d id not s a v e unea ten ce rea l . T w o th i rds of the mothers s ta ted that they 'a lways ' or 'a lmost a lways ' p repared the baby ' s food . T h e pe rson , other than the mother, c i ted a s ' somet imes ' feeding the infant w a s the father, or the nanny or babysi t ter . Ques t i ons B 8 to B11 were d e v e l o p e d to identify how c lose ly cerea l w a s fed to other l iquid foods s u c h a s breast milk in order to identify ' comp lex food mixtures ' that infants were fed . Iron bioavai labi l i ty is known to differ depend ing on the type of foods that are comb ined together. Mos t of the mothers (5/9) s ta ted that they fed ce rea ls ' a lways ' , 'a lmost a lways ' , or ' somet imes ' twice per day . A lmos t half the mothers (4/9) s ta ted that they 'a lways ' or 'a lmost a lways ' f ed ce rea l o n c e per day . A few mothers (2/9) fed ce rea l three t imes per day . A l l of the mothers stated that they 'a lways ' fed ce rea l eve ry day of the week . T h e mothers stated that they fed ce rea l ei ther at fami ly mea l t imes (4/9), morn ings on ly (3/9), even ings on ly (2/9), be tween fami ly mea l s (1/9), or at another t ime (lunch) (1/9). Ques t i ons 8, 9, a n d 11 cou ld be c o m b i n e d a n d a s k e d on a d iagram of a 2 4 hour c lock, in order to elicit mo re accu ra te da ta on t iming be tween feed ing the var ious sol id and l iquid foods . T h e last ques t ion w a s an o p e n - e n d e d ques t ion that a s k e d about what in f luenced how m u c h ce rea l the baby ea ts . T h e r e s p o n s e cou ld have b e e n a n s w e r e d in relation to the mothers ' percept ions at the present t ime, or in genera l over the last few months . Mos t of the mothers (5/9) responded that they felt that hunger w a s a determinant of ce rea l consumpt ion . S o m e mothers 117 RESULTS r esponded that infant t i redness (3/9) and fami ly interact ion or attention (3/9) was important. Tee th ing (1/9), locat ion of feed ing (1/9), a n d activity leve l dur ing the day (1/9) were a l so c i ted by different mothers a s factors important to the amount of ce rea l their infant c o n s u m e d . T h e mothers ' t iming of ce rea l feed ing (i.e. w h e n the infant is hungry and not tired) a s wel l a s the interact ion a round the mea l t ime itself a p p e a r e d to be the key factors ci ted as important to ce rea l consumpt ion . T h e s e factors were a l so found to be important f rom the interview data ana lys i s . T h e da ta obta ined f rom the 12 s ing le r e s p o n s e ques t ions in this sect ion captured da ta , aga in , most ly at o n e t ime point. T h e s p r e a d s h e e t format s e e m e d more effect ive in obta in ing greater detai l , and thus potential ly a better unders tand ing of the mothers ' ce rea l feed ing prac t ices (type and brands) ove r t ime. T h e da ta that were gathered both in the sp readshee t format and the ques t ion format, never the less , p rov ided important informat ion. Howeve r , improvements c o u l d b e m a d e by us ing an hour ly c lock format to obtain da ta o n w h e n in the day infants a re fed var ious foods . T h e intent of the s e c o n d s p r e a d s h e e t in the ques t ionna i re w a s to attempt to capture ce rea l feed ing prac t ices over t ime and identify how pract ices p rog ressed a s the infant a g e d . S e v e n mothers r e s p o n d e d to the quest ion on what they m ixed their ce rea l with. Al l of the mothers , who responded to the ques t ion (6/6), had m i x e d c e r e a l with fo rmula . S imi la r to the s ing le r e s p o n s e da ta , most mothers (5/6) used breastmi lk , and half of the mothers used water. O n e mother u s e d both ju ice and yogurt. O n e mother u s e d f ive different l iquids to mix ce rea l with (breast milk, fo rmula , water, ju ice, a n d yogurt) . T h e sp readshee t format captured the different mix ing patterns ove r t ime. Interestingly, of the 5 mothers who u s e d breast milk to mix ce rea l with, 2 used it for 1 month e a c h , and 3 u s e d it for 3 months . M o s t of the mothers (5/7) p rog ressed to mix ing ce rea l with infant fo rmula after hav ing first m ixed the ce rea l with breast milk. T h e s p r e a d s h e e t s i l lustrate the type and brand of ce rea ls the mothers u s e d . M a n y mothers (5/9) sw i tched be tween 2 different b rands . S o m e mothers (3/9) swi tched be tween 3 b rands and on ly 1 mother u s e d on ly one b rand . In addi t ion, mothers reported us ing be tween 1 to 5 different t ypes of ce rea l . O n e mother u s e d 1 type, 3 mothers used 2 types, 3 mothers u s e d 3 118 RESULTS t ypes, and 1 mother e a c h u s e d 4 a n d 5 different types of ce rea l s . N o mothers interviewed used toddler or other ce rea l s . M a n y mothers (5/9) u s e d 3 or more types of ce rea l . S e v e n ques t ions w e r e d e v e l o p e d in sec t ion C of the quest ionna i re to elicit d a t a o n the mothers ' ce rea l pu rchas ing dec i s i ons and prac t ices . T h e s e ques t ions were inc luded b e c a u s e they m a y reflect, to s o m e deg ree , the mothers ' ce rea l feed ing pract ices. Al l of the mothers stated that they 'usual ly 1 p u r c h a s e d the baby ce rea l . O n l y one father w a s c i ted a s purchas ing ce rea l s . T h e mothers s tated that they ei ther p u r c h a s e d infant ce rea l at the grocery store (8/9) or the drug store (7/9). Mos t of the mothers s tated c o n v e n i e n c e (7/9) a n d good se lec t ion (6/9) a s the main reasons for pu rchas ing c e r e a l s at the locat ion they d id . A lmos t half of the mothers (4/9) s tated that better pr ices were a factor in the locat ion that they s h o p p e d at for infant ce rea l s . M a n y of the mothers (6/9) sa id they p u r c h a s e d ce rea l a s part of a routine shopp ing trip and m a d e spec i f ic trips to spec i f i c s tores to p u r c h a s e ce rea l s . O n e third of the mothers sa id they did not pu r chase ce rea l a s part of a routine shopp ing trip nor m a d e spec i f i c tr ips to spec i f ic s tores to pu r chase ce rea l s . Interestingly, mos t of the mothers (7/9) stated that they pu rchased only 1 box of ce rea l at a t ime. S o m e of the mothers (4/9) p u r c h a s e d seve ra l boxes of different types and fewer mothers (2/9) stated that they p u r c h a s e d seve ra l b o x e s of the s a m e type of ce rea l . On l y 1 mother bought a large supp ly of ce rea l . The re were f ive ma in o p e n - e n d e d r e s p o n s e s c i ted by the mothers a s important to infant ce rea l b rand a n d type se lec t ion . T h e responses , in the order of most f requent ly c i ted were ; b rand e x p o s u r e and packag ing information (4/9), what w a s on sa le (3/9), know ledge /adv ice or baby p re fe rences (2/9 each ) , and contents (1/9). It is of interest that the 'market ing ' (7/9) a p p e a r e d to have the most inf luence o n the mothers ' ce rea l type and brand se lec t ion , c o m p a r e d infant food p re fe rences (2/9) or the content (1/9). Eight ques t ions we re d e v e l o p e d in sec t ion D of the quest ionna i re to exp lore the mothers ' percept ions of her infant 's a c c e p t a n c e of commerc i a l infant ce rea l s , the infant's diet a n d appet i te and the mother 's level of c o n c e r n about so l id food intake. Mos t of the mothers (7/9) s tated that their infant had re fused to eat c o m m e r c i a l baby c e r e a l . In addi t ion, m a n y mothers s tated their infant preferred spec i f i c textures(6/9) , l iked a var iety of ce rea ls (5/9), and l iked different me thods of prepar ing ce rea ls (7/9). A l though two thirds of the mothers s tated that their infant ate infant 119 RESULTS cerea l if they had other c h o i c e s , one third s tated that they d id not. Interestingly, many mothers r e s p o n d e d that their infant 's diet w a s nutrit ionally 'very g o o d ' to 'excel lent ' (6/9), that their infant 's appet i te w a s a l so 'very good ' to 'excel lent ' (7/9), yet they a l so a p p e a r e d to have conce rns about their infant 's food intake (6/9). Unfortunately, s i n c e t h e s e ques t ions we re a s k e d at o n e point in t ime, it is not c lear f rom the da ta , at what a g e ce rea l s were re fused, how mothers r esponded to their infant 's refusal of c e r e a l , at wha t age(s) the mothers h a d c o n c e r n s about food intake, o r what the food c o n c e r n s were . Fi f teen ques t ions were d e v e l o p e d in sec t ion E of the quest ionna i re to identify what information about feed ing so l id foods the mother m a y have u s e d . T h e quest ions dif ferentiated be tween the information that w a s rece ived ve rsus that wh ich w a s sought and its pe rce ived use fu lness . A l l of the mothers s tated that they both rece ived and sought information t hemse l ves on introducing sol id foods . In addi t ion, al l of the mothers s tated that the information that they rece ived in f luenced their feed ing prac t ices and most mothers s tated that the information they ob ta ined t hemse l ves (7/9) in f luenced their feed ing prac t ices . Of interest, m a n y of the mothers (6/9) s ta ted the information they rece ived and the information they sought t hemse l ves (7/9) w a s not adequa te to meet their n e e d s . M a n y mothers rece ived information at birth or in hospi ta l (5/9), or at about 3 months post par tum (4/9). Mos t of the mothers (8/9) sought information later be tween 2 to 6 months , a l though a few (2/9) did s o at birth a s wel l . The re were f ive s i tes whe re the mothers rece ived informat ion; the parent infant g roups , their doctor , the Hosp i ta l , by mai l and f rom fr iends. T h e mothers sought information at most of t hese s i tes a s wel l , but ins tead of the Hosp i ta l , they sought information at the publ ic heal th unit, the books to re , the library, and f rom formula manufacturers and food packag ing . T h e mothers , in genera l , a p p e a r to have rece ived more information than they sought . Ve rba l information w a s rece ived f rom the publ ic heal th nurse , doctor , nutritionist, parent infant group, a n d f r iends w h e r e a s informat ion in print w a s rece ived by mothers f rom char ts on t iming of so l id food introduct ion, handouts on how to m a k e your own food , books and commerc ia l informat ion. Further, the mothers sought informat ion f rom the publ ic heal th nu rses , the Nutrit ionist, f r iends, books a n d art ic les. T h e information that the mothers rece ived and found 1 2 0 RESULTS most helpful cou ld be d e s c r i b e d us ing their own words ; "a l l w a s useful" and "it 's a good introduct ion". S o m e mothers ment ioned that the t ime char ts were good b e c a u s e they gave the order foods were to be in t roduced and an age appropr ia te pract ical t imel ine. Other mothers stated that the information w a s spec i f i c and prov ided s o m e detai l , 1 mother stated that the doctors ' adv i ce w a s t rus ted. Of the informat ion that the mothers sought , they stated that they found other mothers ' e x p e r i e n c e s , i deas , educa ted judgement and one to one information that w a s speci f ic and deta i led , the most usefu l . In addi t ion, the c o m m e n t s about what information they wou ld have l iked, cou ld be desc r i bed us ing the ph rase - "more detai l" . T h e mothers wan ted more detai l in the t imel ines, more detai l spec i f i c to f inger foods and texture, dai ly mea l p lans and al lergy prevent ion. O n e mother s tated s h e wou ld h a v e l iked books on nutrition and v i tamins. T h e format u s e d to elicit r e s p o n s e s that cou ld d is t inguish be tween information that the mother rece ived v e r s u s what s h e sought at tempted to elicit da ta on the mothers ' v iewpoint about the ava i lab le resou rces . T h e results of the sec t ion E quest ionna i re da ta were useful s i nce the da ta a d d e d addi t ional detai l that supp lemen ted a s wel l a s suppor ted the interview da ta . A l though the quest ionnai re d id not elicit information about the mothers ' fee l ings about be ing a 'first t ime mother" (i.e. inexper ience) or the impor tance of ' r e a s s u r a n c e ' to the mother, concep ts d i s c o v e r e d f rom the interview da ta , they cou ld be eas i ly incorporated into the quest ionnai re. T h e information gathered f rom the ques t ions about what information w a s rece ived or sought ( E 1 a and E2a) and the locat ion that the mother w a s g iven , or had sought , information (E1c and E2c) w a s a n s w e r e d with s imi lar or the s a m e a n s w e r s . It m a y be poss ib le to o rgan ize these quest ions in a table format to he lp responden ts answer , more eas i ly , s u c h ques t ions that are c lose ly related yet sl ightly different (i.e. what informat ion did you rece ive v e r s u s where did you rece ive information). T w o ques t ions we re d e v e l o p e d in sec t ion F of the quest ionna i re to identify so l id food feed ing prac t ices , o ther t han c e r e a l feed ing prac t ices . T h e ques t ions g ive an e x a m p l e of the d a t a that wou ld be co l lec ted f rom this format. A l though al l of the mothers had introduced vege tab les to their infant, 1 had not g iven fruit to her infant. Mos t of the mothers (7/9) had not in t roduced e g g , and many had not g i ven c h e e s e s (4/9), or yogurt (3/9) at the t ime of the interview. Interestingly, most mothers s tated that they had int roduced mea ts (7/9). T h e 2 mothers ' who had not 121 RESULTS in t roduced mea ts , ind icated that they in tended to do s o at about 8 months . T h e results f rom this format, a l though highly conduc i ve to quant i f icat ion, do not prov ide important detai l about the feed ing p r o c e s s (i.e. the spo rad i c feed ing of meat over t ime) that the interview da ta and/or the da ta f rom the sp readshee t format in the quest ionna i re were ab le to elicit. T h e intent of the third sp readshee t in the quest ionna i re w a s to elicit da ta on the mothers ' so l id food feed ing prac t ices , other than ce rea l feed ing pract ices, accord ing to the infants' age . A l l of the mothers fed their infants vege tab les a n d a l l , excep t 1, fed their infant fruit at the t ime of the interview. Of the three mothers who indicated start ing fruits and/or vege tab les at 4 months , 1 fed about 3 to 4 t ab lespoons of e a c h per d a y f rom 4 to 7 months . O n e mother fed about 1 tab lespoon of e a c h per d a y work ing up to 1 sma l l jar of e a c h per day be tween 7 to 8 months . T h e other mother fed about 2 t e a s p o o n s of fruit only per day work ing up to Vz jar of fruit 3 t imes pe r w e e k a n d Vz jar of vege tab les pe r d a y at 7 months . T w o mothers started fruit or vege tab les at 5 months of age . O n e of t hese mothers fed about one half a t e a s p o o n but worked up to V* cup of e a c h per d a y by 7 months and 1/3 cup of e a c h per d a y by 8 months of age . T h e other mother fed about 6 t ab lespoons of vege tab les per day f rom 4 to 7 months and no fruit. O n e mother started fruit at 6 months and fed about 1 to 2 t e a s p o o n s of fruit per day work ing up to inc luding 3 ice c u b e s i ze c h u n k s of h o m e m a d e vege tab les per d a y 8 months of age . T h e approx imate amoun ts of fruit a n d vege tab les fed to the indiv idual infants di f fered substant ia l ly at initial introduct ion, a s wel l a s ove r t ime. T h e three s p r e a d s h e e t s were d e v e l o p e d for the quest ionna i re to identify the types, b rands and amoun ts of l iquids, ce rea l s , and other so l id foods that mothers fed their infants over t ime. In addi t ion to the interview da ta , this type of information a l so a ided in identifying the factors within the feed ing context that m a y inf luence the infant 's a c c e p t a n c e or consumpt ion of iron fortified infant ce rea l s . 122 DISCUSSION Chapter V 5.1 Determinants of solid food feeding practices A mother 's so l id food feed ing prac t ices , wh ich are de te rmined, in part, by the infant's feed ing behav io rs , her percept ions , know ledge a n d ski l ls must be appropr ia te to meet the infant's evolv ing nutritional requ i rements dur ing the transit ion per iod (4 to 9 months) . P rev ious studies have s h o w n that infants of 9 months of a g e w h o are not bott le-fed with iron-fortif ied fo rmu la are at high risk for iron de f i c iency a n e m i a and low iron s to res . It is a l so known, b a s e d on iron needs in the first year of life a n d the iron content of h u m a n milk, that iron f rom comp lemen ta ry foods is essent ia l to prevent iron de f i c i ency a n e m i a a n d iron deplet ion in breast - fed infants of 9 - 12 months of a g e . T h e purpose of this s tudy w a s exploratory, to learn about how mothers feed their infants and what de termines the w a y that they f eed so l id foods dur ing the transi t ion per iod . T h i s informat ion is important to deve lop effect ive educa t i on st rategies that will improve comp lemen ta ry so l id food feed ing prac t ices and hence , the iron intake of infants at r isk. T h i s resea rch identif ied 5 t h e m e s that a re centra l to the sol id food feed ing p r o c e s s , a n d that o c c u r at 3 ma in levels - the mother, the infant, and the env i ronment . A 3 -d imens iona l concep tua l mode l of infant so l id food feed ing has b e e n deve loped to il lustrate t hese t hemes (Figure 10). A s e c o n d concep tua l mode l has b e e n d e v e l o p e d us ing a c a u s a l - c o n s e q u e n c e mode l (G laser , 1978) to i l lustrate the sol id food feed ing p r o c e s s . T h e s e c o n d mode l (F igure 15) l inks the re lat ionships be tween the 5 t h e m e s and sugges t s the potent ial c o n s e q u e n c e of the mothers ' so l id food feed ing pract ices spec i f ica l ly to d ietary a d e q u a c y (i.e., iron). In this chap te r the most important a s p e c t s of t hese f indings will be d i s c u s s e d . Further, the s tudy l imitat ions a r e out l ined a n d the potent ial app l ica t ion of the f ind ings to future r e s e a r c h and pract ice will be d i s c u s s e d in C h a p t e r VI. So l id food feed ing is c o m p l e x and invo lves interact ions at m a n y levels . W h e n v iewed simpl ist ical ly, if nutrient n e e d s a re to be met then 1) the mother must prepare and offer food of the required nutrit ional quality, and 2) the infant must eat it. T h e resul ts of this s tudy c lear ly s h o w that al l mothers started so l id food feed ing a n d al l the mothers had the know ledge to introduce iron-fortified infant ce rea l at 4 - 6 months . T h u s , lack of know ledge of w h e n to in t roduce iron-fortified sol id foods is not l ikely 123 DISCUSSION to be the p rob lem that c a u s e s a high inc idence of iron deplet ion in breast- fed infants. P rev ious s tud ies have reported that infants had b e e n in t roduced to so l id foods prior to 4 months of age (Tanaka et a l . , 1987, Y e u n g et a l . , 1981 , G r e e n e - F i n e s t o n e et a l . , 1989, C la rk et a l . , 1981 , Wi l l i ams et a l . , 1996). T h e r e has b e e n a trend towards a later (more appropr iate) age of introduction of so l id foods over the past 20 yea rs . W i l l i ams et a l . (1996) found that on ly 7 . 8 % of the infants in V a n c o u v e r had been given i ron- fortif ied infant ce rea ls before 4 months of a g e . In contrast , ear l ier work by T a n a k a et a l . (1984-85) and G r e e n e - F i n e s t o n e et a l . (1989) found that 4 2 % and 3 4 % of infants, respect ive ly , had been int roduced to so l ids by 3 months of age . P rev ious to this, s tud ies in the 1970 's found that 70 - 7 8 % of infants had b e e n in t roduced to so l ids prior to 4 months of a g e (Clark et a l , 1981). T h e transcr ipts f rom the f ace - to - f ace interviews with mothers in this s tudy prov ide amp le ev i dence of know ledge regard ing the r e c o m m e n d e d a g e s for so l id f ood introduct ion, with ex tens ive d i s c u s s i o n a round the perce ived infant 's so l id food l ikes and d is l i kes . T h e f indings of this s tudy sugges t more diff iculties revo lved a round the infant eat ing the iron conta in ing food , than the mother not knowing what food to offer. Th i s c a n be s impl is t ica l ly d iv ided into how the mother p repares and presents the food , w h e n in the day s h e offers the food , how s h e m a n a g e s the feed ing env i ronment (i.e., the feed ing dynamic ) , how s h e interprets the infant 's food c u e s , and the infant's a c c e p t a n c e of the food . T h e mothers who part ic ipated in this s tudy took f rom 2 w e e k s to over 3 months f rom the t ime of initial so l id food ' introduct ion' at tempts to a c h i e v e (start) routine feed ing of iron-fortified infant ce rea l s . Th i s m a y be due to infant factors (i.e., f lexible/ inf lexible personal i ty , 'good ' / ' fussy ' eater) or mother factors (i.e., f eed ing strategies) . T h e t ranscr ipt d a t a c lear ly s h o w that there w a s difficulty with ce rea l a c c e p t a n c e (quantity a n d rate of accep tance ) for s o m e infants. T h e mothers desc r ibed this per iod a s ' sporad ic ' ce rea l feed ing . R e v i e w of the pub l i shed l i terature o n infant feed ing ind icates that there is a lack of da ta o n the t ime over wh ich mothers ach ieve appropr ia te so l id food in takes. T h u s , the concep ts - sporad ic and routine ce rea l feed ing , a d d to the current body of l iterature. La rge quanti tat ive populat ion s tud ies invest igat ing the growth and/or nutrient s tatus of young infants (Walter et a l . , 1993 ; D e w e y et a l . , 1998 ; Innis et a l . , 1997; C a l v o et a l . , 1990 ; P i za r ro et a l . , 1991 ; He in ig et a l . , 1993) have used the ' age of introduct ion of so l id foods ' a s a var iab le for identifying factors that inf luence infant iron status or growth. P iza r ro et a l . , (1991), Wa l te r et a l . , (1993) and others (S i immes et a l . , 1984) have s h o w n an i nc reased risk of iron def ic iency a n e m i a in infants after about 6 months of a g e if addi t ional comp lemen ta ry s o u r c e s 124 DISCUSSION of iron are not provided. However, the findings of this study show that it is important to identify not just the age of first introduction, but also if and for how long the infant has been fed cereals 'routinely1 or 'sporadically'. It is suggested that future investigations of dietary iron adequacy should include the quantities of iron-fortified cereal consumed over time. The transcripts from this study show that the reasons mothers' gave for starting solid food (advice, perceptions of readiness for solids, wanting the infant to sleep during the night) were different from the reasons that they gave for making decisions over what solid foods to feed (selection). The mothers' perceptions of the infants' food behaviors appeared to strongly influence subsequent solid food feeding practices and how mothers' progressed in their feeding behavior (starting the feeding process and offering solid food). The transcripts suggest that the mothers observed their infant's cues and interpreted them as 'yes' (the infant is ready, prefers a specific food, wants food or is hungry) or as 'no' (the infant is not ready, does not like a specific food, does not want food or is not hungry). Comments on food refusal were common and might have been interpreted by the mother correctly or incorrectly as the infant not being 'ready1 for solid foods or disliking the food. It seems likely, based on the transcripts that some mothers may have misinterpreted the infants' food refusal cues as the infant not being 'ready1 for solids, and this interpretation impacted the rate at which solid foods were fed to these infants. This study found that the acceptance or rejection of solid foods was the major determinant of mothers' food selection and feeding choices throughout the transition process. The infant's response is, therefore, an important variable in the mother's solid food feeding practices, and as a result it is illustrated as a crucial component of the feeding process in both the 3-dimensional and the causal-consequence models (Figures 10 and 15). The mothers perceived that their infant's food taste and texture preferences influenced acceptance of the solid food that was offered, and they could also link their observations of infant behavior to their current or past solid food feeding strategies. The findings of this study also suggest that infant food acceptance or rejection directly affected the adequacy of iron-fortified cereal consumption. Infant feeding guidelines published for mothers in the "BABY'S FIRST FOODS" information sheet (B.C. Ministry of health, 1996) recommend feeding solids 1 -2 times per day, starting with 1 teaspoon of iron-fortified cereal and increasing to 4 tablespoons per day from 4 to 6 months of age. From 6 to 9 months, mothers are instructed to feed their infant solid foods 3-4 times per day and more specifically, to feed 4 to 8 tablespoons of infant cereal daily as well as introducing other iron containing 125 DISCUSSION foods s u c h a s meat , f ish, and poultry. T h e resul ts of this s tudy s h o w that there are seve ra l cr i t ical i s s u e s with regards to the pract ical app l icat ion of current infant feed ing recommenda t ions by mothers . First, the most f requent so l id food rejected by the infants w a s iron-fortified ce rea l . Further, all of the mothers in this s tudy used a 'mix ing ' strategy to i nc rease or mainta in food a c c e p t a n c e (mixing to alter taste/texture) o r get so l id food ea ten (mixing d is l i ked f oods with preferred foods) . Th i rd , the number of mothers a m o n g these more highly educa ted and mot ivated s tudy part ic ipants who a c h i e v e d the r e c o m m e n d e d feed ing of 4 t ab lespoons of ce rea l per d a y by 6 months of a g e w a s low (4/12). Last ly , it took 3 months for m a n y of the mothers (6/12) to reach routine feed ings of V* cup of ce rea l per d a y f rom the reported initial a g e of ce rea l introduction. C lear ly , it is r e a s o n a b l e to conc lude that the intake of iron f rom iron-fortified infant ce rea l di f fered a m o n g the infants in this s tudy. Th i s s tudy found that the mothers u s e d numerous and d i ve rse infant feed ing st rategies. T h e transcript da ta sugges t that the infant 's dietary intake m a y have dif fered depend ing on the st rategy that the mother u s e d . T h e sol id food feed ing s t rategies used by the mothers a re represented by the t h e m e - w a y s of feed ing . N o literature on infant feed ing that w e know of has desc r i bed sol id food feed ing s t ra teg ies. Th i s f inding a d d s to the b o d y of know ledge on infant feed ing and i nc reases the unders tand ing of the link be tween the feed ing behav io rs , infant food a c c e p t a n c e , and the s u c c e s s of the so l id food feed ing p r o c e s s with regards to nutrit ional a d e q u a c y . T h e range of infant feed ing s t ra teg ies identif ied by this resea rch c a n be simpl ist ical ly desc r i bed a s s t rategies that poss ib ly p romote (posit ive), a re ineffective (neutral), or cou ld be cons ide red a s d iscourag ing (negative) so l id food a c c e p t a n c e . T h e mothers d i s c u s s e d in detai l how they p repared a n d fed their infant so l id foods . T h e mothers u s e d seve ra l feed ing s t rategies that appea red to be in r e s p o n s e to infant food p re fe rences ; these s t ra teg ies a p p e a r e d to be r e s p o n s e s (changes) in the mother 's feed ing behav io r to d e c r e a s e the infant 's reject ion of the food . T h e s e st rategies inc luded swi tching (types of food and/or b rands of cerea ls ) , mix ing (to alter taste or textures of ce rea ls a n d other so l id foods) , sneak ing or camouf lag ing food (mixing preferred foods with d is l iked foods to get the food eaten) and poss ib ly holding back spec i f i c accep ted foods in o rder to a c h i e v e a c c e p t a n c e of a d is l iked food . T h e mothers a l so a p p e a r e d to be chang ing 'when in the d a / they offered the food , labe led a s adjusting feed ing m a n a g e m e n t , to improve food a c c e p t a n c e . T h e s e strategies of chang ing w h e n the infant w a s fed inc luded adjust ing the f requency of f eeds , 126 DISCUSSION the order in wh ich foods were fed , adjust ing feed ing rout ines and poss ib ly holding back l iquids (e.g. , breast- feeding) to i nc rease hunger . T h e transcr ipts for this s tudy a l s o g ive ev i dence that how the mother interpreted her infant 's food c u e s m a y have de termined the feed ing s t rategies that were u s e d . T h e strategies that m a y have b e e n u s e d in r e s p o n s e to the mother ' s interpretat ion of infant r ead iness for food we re offering the s a m e foods repeatedly whether the infant l iked or d is l iked the food, waiting for the infant to b e c o m e interested, a n d wi thholding food b e c a u s e of pe rce i ved a l lergy risk, chok ing risk, and texture difficulties ( immatur i ty/unready). Further, the st rategy positioning the infant hor izontal ly (e.g. lying on back) to promote swa l low ing m a y reflect a s t ra tegy to dea l with the infant's deve lopmenta l read iness (e.g., infant w a s not ready) . T h e feed ing s t rategies that s e e m e d most l ikely to have had a negat ive effect on the feed ing dynamic / re la t ionsh ip we re prying/stuffing/ forcing the infant to eat, positioning (restraining infant in c a r seat ) , sneaking/camouflaging or hiding (d is l iked foods mixed with l iked foods) and distracting (using toys to alter d y n a m i c s to get f ood ea ten) . W h i l e poss ib ly posi t ive s t ra teg ies m a y have inc luded socializing ( family mea ls ) , modeling or mimicking how to eat, engaging (giving the infant s o m e d e g r e e of control in feed ing by a l lowing them to hold the s p o o n , and playing (food p lay - explor ing). T h e c lass i f icat ion of so l id food feed ing st rategies in this s tudy sugges t s patterns of how so l id foods were fed to the infants by the different mothers in this s tudy. C o m m e r c i a l infant ce rea l is fortified with iron a n d is the on ly app rec iab le s o u r c e of comp lemen ta ry f ood iron fed to most infants under 7 - 9 months of a g e . Su l l i van and B i rch (1994) invest igated repeated exposu re of the s a m e or s imi lar f oods o n vege tab le a c c e p t a n c e a n d found that all the infants (n=36) in their s tudy i nc reased their vege tab le intake after repeated exposu re . S i n c e breast - fed infants had a greater vege tab le intake than fo rmu la fed infants, the au thors s u g g e s t e d that b reas t - feed ing might facil i tate sol id food a c c e p t a n c e . B i rch et a l . (1998) found that the number of feed ings n e e d e d to i nc rease the intake of a s imi lar c o m p a r e d to a novel food di f fered. Infants of 4 - 7 months a c c e p t e d s imi lar foods eas i l y after exposu re , w h e r e a s they did not accep t different f oods (e.g. , vege tab le c o m p a r e d to fruit) eas i ly . Further, M e n n e l l a and B e a u c h a m p (1997) reported that both ce rea l a c c e p t a n c e a n d the quant i ty of ce rea l c o n s u m e d by breast - fed infants w a s in f luenced by the preparat ion method . T h e infants c lear ly preferred ce rea l p repared with a l iquid that they l iked (mother 's milk c o m p a r e d to water) , c o n s u m e d it at a faster rate, and preferred the mixture m a d e with the mothers milk w h e n it w a s of fered to t hem a Vz hour later. T h e t ranscr ip ts f rom this s tudy s h o w that al l 127 DISCUSSION of the mothers used a ce rea l 'mix ing ' s t rategy to i nc rease so l id food a c c e p t a n c e . Th is sugges t s that the mothers modi f ied how they p repared their infant 's food to ach ieve a c c e p t a n c e and/or to comp ly with infant f ood p re fe rences . T h u s , it s e e m s l ikely, that in the natural feed ing context infant f ood a c c e p t a n c e and p re fe rences are c lose ly intertwined with the mother 's feed ing strategy (how the food is p repared) . T h e mothers in this s tudy desc r i bed 3 'mix ing ' me thods , wh ich c a n all be desc r ibed a s "preparat ion of a comp lex m e a l ' . T h e 3 me thods were commerc ia l l y p re -mixed ce rea l comb ina t ions (e.g. ce rea l with fruit), h o m e m a d e mixtures us ing a combina t ion of commerc i a l infant cerea l with fruit, vege tab les , or yogurt, or feed ing other so l id foods at the s a m e t ime a s cerea l but 'on the s ide ' . A l though the mothers u s e d different preparat ion s t rategies to alter the food taste and/or texture and thus i nc rease a c c e p t a n c e , these 3 mix ing me thods might in f luence ce rea l a c c e p t a n c e and hence consumpt ion differently. Further, 'mix ing ' a s a st rategy to ga in a c c e p t a n c e ra ises the quest ion of potential d i f fe rences in iron absorpt ion s e c o n d a r y to the type of food c o m b i n e d with the c e r e a l . T h e form of iron in infant ce rea l is n o n - h e m e iron, wh ich has a w ide range of absorpt ion of 5 - 2 0 % , depend ing on factors enhanc ing or inhibiting iron absorp t ion in the diet (Hal lberg, 1989), and the iron status of the indiv idual . T h e major factors enhanc ing the absorp t ion of n o n - h e m e iron inc lude asco rb i c ac id , meat and f i sh , a n d organ ic ac i ds (citric, lactic, mal ic , a n d tartaric ac ids ) . T h e major factors that inhibit n o n - h e m e iron absorpt ion inc lude; phytates ( found in high f iber ce rea ls ) , i ron-binding po lypheno ls found in t ea a n d cof fee, vege tab les and fruits, s o m e proteins (egg a lbumin , and l egume protein), and s o m e inorganic e lements (ca lc ium) (Fai rweather-Tai t , 1989) . T h u s , d e p e n d i n g o n the food combina t ion , i ron absorp t ion f rom cerea l or breast milk m a y be e n h a n c e d or inhibi ted. Fo r e x a m p l e , in the context of m ixed food combina t ions , the phytates in the ce rea l m a y in f luence h u m a n milk iron absorpt ion if ce rea l s a re fed in c l o s e proximity to b reas t - feed ing . Ano the r e x a m p l e is the po l ypheno ls in vege tab les a n d fruits or the ca lc ium in yogurt that m a y d e c r e a s e the absorpt ion of iron f rom infant ce rea l . Recent ly , E n g e l m a n n et a l . , (1988) found that n o n - h e m e iron absorp t ion by infants w a s i nc reased to 1 5 % from 9 . 9 % w h e n meat w a s a d d e d to a vege tab le mixture. T h i s s u g g e s t s that iron absorp t ion f rom infant diets of low or in termediate iron bioavai labi l i ty cou ld be improved by c h a n g e s in the preparat ion method to inc rease the bioavai labi l i ty of the iron present . 128 DISCUSSION T h e transcript results f rom this s tudy a l s o s h o w that the progress ion of the feed ing p r o c e s s ref lected a mother 's ' learn ing ' on how to feed her infant. T h e results sugges t that the mother 's know ledge , sk i l ls a n d feed ing capabi l i ty we re important determinants of the abil ity to modi fy feed ing st rategies in r e s p o n s e to pe rce ived infant food c u e s . Fo r severa l mothers, the 'initial' feeding behav io rs a p p e a r e d to be ' force ' feed ing , desp i te phys i ca l s i gns f rom the infant that they did not want food . T h e feed ing s t ra teg ies prying/stuff ing/forcing, d ist ract ing, sneak ing or camouf lag ing food , and push ing o r holding back food might c a u s e diff icult ies in feed ing and poss ib ly reflect gaps in the mother 's know ledge , ski l ls a n d thus capabi l i ty . Sat ter (1990) noted that effect ive feed ing inc ludes behav io rs that are suppor t ive a n d p romote posi t ive feed ing d y n a m i c s . T h e food refusal d i s c u s s e d by s o m e mothers in this s tudy cou ld be exp la ined by seve ra l fac tors s u c h a s inappropr iate t iming, inappropr iate expecta t ions about the quant i ty of food an infant shou ld eat, mis interpreted food pre fe rences c u e s , and l imited opportuni t ies for the infant to exp lore the food of fered. T h e infant c u e s desc r i bed , s u c h as spitt ing food out or retching cou ld indicate a lack of infant deve lopmenta l read iness (gag and swa l low reflex not fully mature), or a l ternately an inappropr iate feed ing method (i.e., push ing the s p o o n too far back in the infant 's mouth) . "Turn ing d o w n food , spit t ing it out, not open ing mouth , turning h e a d ' etc., a re behav io rs that cou ld a l s o indicate a n infant's p re fe rence for sweet rather than bitter f lavors (Menne l la a n d B e a u c h a m p , 1998). T h u s , the interpretation of food refusal invo lves both the mother 's interpretation of the var ious food c u e s , the mother 's feed ing ski l l a n d knowledge of infant deve lopment and behav ior , a s wel l a s the feed ing re lat ionship. T h e o u t c o m e in the p rogress ion of feed ing is dependen t on how the mother adapts a n d what s h e learns f rom the infant 's r esponse to her act ions. Infant feed ing gu ide l ines ( C P S , 1998; B . C . Minist ry of Hea l th , 1996) have not a d d r e s s e d i s s u e s of infant food a c c e p t a n c e a n d re fusa l , or the c o m p l e x a s p e c t of 'how' to f e e d infants so l id foods . T h e f ind ings of this r esea rch s h o w that mothers recogn ize c o n c e p t s f rom the infant feed ing gu ide l ines s u c h a s genera l read iness , food p re fe rences , hunger or sat iety c u e s , a n d they know w h e n to introduce first foods (cereals) . Howeve r , in the c a s e of f ood re fusa l , it s e e m s l ikely that mo the rs m a y not h a v e the know ledge or ski l ls to r espond appropr iate ly. F ive t h e m e s were identif ied a s crit ical to so l id food feed ing dur ing the transit ion per iod and we re def ined a s the feeding process, perceiving infant food needs, ways of feeding, gaining expertise a n d tailoring the transition process. T h e s e t h e m e s are in terconnected. Wi th in the context of the infant feed ing 129 DISCUSSION p rocess , m a n y factors in f luence 'how' a mother f e e d s her infant. T h e key factors that determine infant sol id food feed ing , b e s i d e s infant food a c c e p t a n c e , a re the mother 's percept ions, feed ing s t rategies a n d her exper t ise. T h i s s tudy identif ied a core t heme - tailoring the transition process that connec ts the other 4 t h e m e s together a n d bes t d e s c r i b e s the mother ' s major feed ing task dur ing the transi t ion per iod . T w o mode ls were d e v e l o p e d to desc r i be the p r o c e s s through wh ich the mother is tailoring her feed ing st rategies. T h e concep t ' tai loring' is central to unders tand ing the infant's dietary p rogress ion (accep tance of an inc reas ing amoun t and range of semi -so l id foods) f rom the exc lus ive ly l iquid diet to a modi f ied adult diet, and unders tand ing dietary iron a d e q u a c y . T o e m p h a s i z e this, the core theme c a n be further desc r ibed a long a d imens ion of ' tai loring' or not ' tai loring' the transit ion p r o c e s s . T h e interview t ranscr ipts c lear ly s h o w that s o m e of the mothers in this s tudy readi ly adap ted and u s e d mult iple st rategies and we re thus tai loring their feed ing prac t ices . O thers , however , u s e d a l imited number of s t ra teg ies. T h e feed ing strategies dif fered in their e f fec t iveness. R e p e a t e d food 'offering' and 'wait ing' for the infant to b e c o m e interested c a n be cons ide red a s 'static ' or not ' ta i lored' in that they a p p e a r e d to not promote sol id food a c c e p t a n c e (i.e., cerea l ) or the p a c e of food transi t ion a s success fu l l y a s other s t ra teg ies. T h e food 'switching' and 'mix ing ' s t rategies c a n be c o n s i d e r e d to be more 'dynamic ' in that the mother ' tai lored' her feed ing strategy acco rd ing to the infant's r e s p o n s e to the food that w a s of fered. T h e swi tch ing a n d mix ing s t rategies a p p e a r e d to be more s u c c e s s f u l in promot ing the a c c e p t a n c e of so l id food and the transit ion p a c e . T h e mothers who were ' tai loring' their so l id food feed ing s t rategies a p p e a r e d to be del iberate ly s e a r c h i n g for 'ways ' to i nc rease food a c c e p t a n c e . A l though this s tudy found t ha t ' tailoring the transition process' w a s the co re theme, the mother 's infant feed ing know ledge , ski l ls and capabi l i ty a re a l so central to unders tand ing the infant's dietary p rogress ion . T h e mother 's pe rsona l growth w a s labe led 'ga in ing exper t ise ' . T h e exper ience of be ing a 'first t ime' mother and need ing infant so l id food feed ing information and suppor t ( including ' reassurance ' ) w a s desc r i bed in detai l in the t ranscr ipts. G r e e n a n d Kreuter (1991) state that learning involves three p r o c e s s e s : direct expe r i ence , indirect or v icar ious expe r i ence f rom the observat ion of others (model ing), and unders tand ing c o m p l e x information to enab le the ant ic ipat ion of c o n s e q u e n c e s of ones own act ions and capabi l i t ies. G r e e n a n d Kreuter (1991) a l so noted that the last p r o c e s s is centra l to the indiv idual 's s e n s e of con f idence in new si tuat ions or c i r c u m s t a n c e s . Further, t hese authors state that the percept ion of 'sel f -ef f icacy 1 or capac i t y for s u c c e s s b a s e d on expe r ience in f luences emot iona l react ions with regards 130 DISCUSSION to anx iety and cop ing abil i ty (G reen a n d Kreuter , 1991). T h e mothers in this s tudy desc r ibed their expe r i ences mov ing a long a ' learn ing curve ' with the relatively new ' c i r cumstance ' of sol id food feed ing . T h e mothers e x p r e s s e d var ious leve ls of frustration with unsuccess fu l initial at tempts at so l id food feed ing , or w h e n the feed ing si tuat ion d id not go a s they had expec ted . A l though most mothers identif ied a n d u s e d n u m e r o u s resources for informat ion on infant feed ing, they c lear ly art iculated gaps in the resou rces ava i lab le for their s i tuat ion and information needs . T h e resources that were used inc luded the pro fess iona l sec to r (health nu rses , nutrit ionists, doctors , communi ty g roups , parent groups and the nutrition hotl ine), p ro fess iona l gu ide l ines a n d char ts , the popular p ress , pamph le ts p repared by b a b y food c o m p a n i e s for products and for food p a c k a g i n g , and the mother 's soc ia l network (family, f r iends a n d mothers ' g roups) . Th i s s tudy found that mothers had the most difficulty with learning 'how' to feed their infant so l id foods , not w h e n or what food to start with. T h e transcr ipts c lear ly identify that the expe r i ence of be ing a 'first t ime m o m ' p roduced fee l ings of uncerta inty in m a n y mothers , a n d this m a y h a v e in f luenced feed ing con f i dence . S o m e mothers s ta ted that they e v e n felt s c a r e d about feed ing their infant. It is poss ib le that mothers who did not have know ledge or expe r i ences of 'how' to f eed their infant so l id food and who had feed ing cha l l enges , s u c h a s food reject ion or c o n c e r n s about s l o w infant weight ga in , were exp ress ing fee l ings that involved percept ions of se l f -ef f icacy a n d their capab i l i t ies . S o m e mothers desc r i bed hav ing to go with their 'own gut feeling' a n d what they thought w a s right or 'best for their baby' with regards to feed ing so l id foods . T h e s e mothers a l s o desc r i bed learn ing to f eed their infant as a 'trial and error 5 p r o c e s s . Th is sugges ts that in learn ing to feed their infant, mothers might p rogress through a 'ref lect ive' learning p rocess that might benef i t f rom peer or p ro fess iona l suppor t that wou ld reinforce posi t ive so l id food feed ing prac t ices or al ternately, redirect negat ive prac t ices . S i n c e learning takes p lace through direct exper ience , a s wel l a s by obse rv ing others (Green a n d Kreuter , 1991) it m a k e s s e n s e that the mothers in this s tudy found that ' expe r i enced ' mothers were mos t helpful a n d that they felt r eassu red through interaction with other mothers at the commun i t y group set t ings. Infant feed ing gu ide l ines ( C P S , 1998 ; B . C . Ministry of Hea l th , 1996) a d d r e s s 'when ' to start feed ing so l id f o o d s a n d 'what first foods ' shou ld b e fed (i.e., iron-fortified infant cerea l ) . T h e f indings f rom this s tudy c lear ly sugges t that mothers m a y n e e d addi t ional resources that focus expl ici t ly on i ssues a round promot ing infant food a c c e p t a n c e and dec reas ing food refusal - the c o m p l e x a s p e c t of 'how 1 to feed infants so l id foods , and i ssues a round be ing a 'first t ime' mother mov ing 131 DISCUSSION through a 'ref lect ive' learning p r o c e s s . Th i s a p p r o a c h , wh ich f o c u s e s on factors that a re related to the mother, the infant and the env i ronment (i.e., resources) wou ld prepare the mother better for the task of 'tailoring the transit ion p rocess ' . 5.2 The conceptual models of infant solid food feeding T h e 3-d imens iona l concep tua l mode l (F igure 10) and the c a u s a l - c o n s e q u e n c e mode l of infant so l id food feed ing (F igure 15) were d e v e l o p e d to il lustrate the determinants of the sol id food feed ing prac t ices dur ing the transit ion per iod of the mothers in this s tudy us ing the t hemes d iscovered in the interview da ta . A concep tua l mode l in qual i tat ive exploratory resea rch is important for integrating f indings. Th rough integration of concep ts a n d ca tegor ies , the ana lys is p r o g r e s s e s f rom being so le ly descr ip t ive to be ing concep tua l and theoret ica l , wh ich is the pu rpose of the g rounded theory method (G lase r a n d S t r a u s s , 1967; G l a s e r , 1978; S t r a u s s a n d C o r b i n , 1990). C o n c e p t u a l mode ls facil i tate the d i scove ry of re lat ionships a m o n g c o n c e p t s a n d ca tegor ies identif ied f rom within the context and are d e v e l o p e d f rom the ana lys i s p r o c e s s itself. Consequen t l y , the sol id food feed ing mode ls deve loped in this s tudy a re 'g rounded ' both conceptua l l y to the interview da ta and d e v e l o p e d f rom the data . T h e s e concep tua l mode l s a d d to present know ledge b e c a u s e they il lustrate the c o m p l e x interaction be tween the mother , infant, food and the factors in the sol id food feed ing context that determined sol id food feed ing prac t ices . T h u s , the mode l s prov ide a f ramework of the infant behav io rs , the mothers ' p rac t ices , a n d the determinants within the mothers ' 'prox imal ' env i ronments that in f luence the abil ity to feed the r e c o m m e n d e d amoun ts of comp lemen ta ry so l id foods during the transit ion per iod . T h e f ramework that p rov ides structure to the mode ls is der ived f rom the c a u s a l - c o n s e q u e n c e mode l (G laser , 1978). T h u s , the feed ing p r o c e s s c a n be desc r i bed accord ing to the context, cond i t ions (genera l , c a u s a l and intervening), the co re ca tegory and the c o n s e q u e n c e s (St rauss a n d C o r b i n , 1990) . Inappropriate ' tai loring' is i l lustrated a s a c o n s e q u e n c e that impacts on sol id food a c c e p t a n c e a n d consumpt ion patterns (iron-fortified infant cereal ) at spec i f i c a g e s . T h e c o n s e q u e n c e s of inadequate dietary iron intake have been s tud ied ex tens ive ly through research identifying the p reva lence of iron def ic iency a n e m i a a n d iron def ic iency in infants. L e s s 132 DISCUSSION research has f o c u s e d o n determinants of so l id food feed ing prac t ices . T w o concep tua l mode ls related to infant feed ing that prov ide a f ramework on the determinants of infant feed ing behav iors (Lutter C K , 2000) , and concep tua l i z ing nutrition p rob lems and c a u s e s of ch i ld undernutr i t ion ( A C C / S C N , 2000) have recent ly been pub l i shed . S imi la r to the f ind ings of this study, the under ly ing c a u s e s of infant feed ing behav io rs a n d inadequate dietary intake d e s c r i b e d in t hese mode ls a re materna l c h o i c e s a n d car ing prac t ices . A t a more distant level , t hese mode l s identify the ' intermediate determinants ' to maternal c h o i c e s - informat ion ( inadequate or inappropr iate), att i tudes (discr iminatory), suppor t (physica l and socia l ) and h u m a n resources (quantity and quali ty). T h e pu rpose of these mode ls w a s to identify and better unders tand what c a u s e s nutrition p rob lems and what opt ions are modi f iable. A s found in this resea rch , cond i t ions within the so l id food feed ing context (i.e., information, support) impact on mother 's feeding behav io rs , and t hese n e e d to be fully unders tood in order to deve lop effect ive educat ion interventions that enab le mothers to feed their infants effect ively to prevent iron def ic iency a n e m i a and iron deplet ion. 5.3 The causal-consequence model of infant solid food feeding T h e c a u s a l - c o n s e q u e n c e mode l of infant so l id food feed ing (adapted f rom G l a s e r , 1978) l inks the p laus ib le re lat ionships be tween the 5 t h e m e s identif ied in this resea rch to dietary a d e q u a c y . T h e so l id food feed ing p r o c e s s in F igure 15 i l lustrates how the var ious condi t ions within the feed ing context in f luence the mother 's ' tai loring' p rac t ices and how these prac t ices cou ld inf luence sol id food a c c e p t a n c e a n d consumpt ion patterns (i.e., iron fortified cereal ) a n d thus dietary a d e q u a c y . On l y a few (3/12) of the mothers in this s tudy a c h i e v e d the r e c o m m e n d e d feed ing of 4 t ab lespoons of ce rea l per day by 6 months of a g e , desp i te the high educa t ion level of the s tudy part ic ipants. F o r half of the mothers (6/12), the interview da ta s u g g e s t e d that it took 3 months before they a c h i e v e d routine feed ing of % cup of ce rea l per day . C e r e a l consump t i on h a d not i n c r e a s e d a b o v e 3 t a b l e s p o o n s of dry ce rea l per day in 2 infants by 7 months of a g e . Th i s sugges t s that mothers might benefit f rom a better unders tanding of 'how' to feed ce rea ls dur ing the transit ion per iod . Wa l te r et a l (1993) found that the liquid feed ing prac t ices in f luenced ce rea l consumpt ion . Infants fed fo rmu la c o n s u m e d a lmos t 30g of ce rea l per day within 3 w e e k s of introduct ion, w h e r e a s it took the breast - fed infants 2 - 3 Vz mon ths to reach intakes of 20 - 133 DISCUSSION 2 5 g m of ce rea l per day . T h i s sugges t s that mothers w h o breast - feed might have more difficulty with the transi t ion p r o c e s s than mothers w h o f e e d fo rmula . Wa l t e r et a l (1993) a l so s h o w e d that the consumpt ion of iron-fortified ce rea l s igni f icant ly in f luenced the iron status of both breast- fed infants and infants fed low iron formula . T h e s e authors reported the 'cumulative' pe rcen tage of infants exc luded f rom this s tudy b a s e d on hemog lob in concent ra t ions be low 105 g/L. A s wou ld be expec ted , the group of infants fed iron- fortified fo rmula had the lowest percent of infants e x c l u d e d . Breast - fed infants who were fed iron-fortif ied ce rea l we re c lear ly at an advan tage with 1 1 % IDA at 8 and 15 months, c o m p a r e d to s imi lar infants not fed a fortified product, with 1 5 % a n d 2 7 % IDA at both 8 and 15 months , respect ive ly . T h e s tudy by Innis et a l , in 1993 in V a n c o u v e r s imi lar ly found abou t 1 5 % IDA a m o n g 9 month o ld breast - fed infants. A s low rate of i nc rease in ce rea l consumpt ion to target levels m a y be an important determinant of iron s tatus, a n d this m a y be exp la ined , in part, by 'hoW the mother is ' tai loring' her feed ing st rategies and thus ach iev ing a c c e p t a n c e . F igure 17 w a s d e v e l o p e d to i l lustrate var ia t ions a m o n g the infants' iron-fortified ce rea l consumpt ion patterns be tween 4 to 9 months of age . S tanda rd i zed tools (e.g., 3-day food records) were not u s e d to col lect the dietary da ta s i nce the focus of the resea rch w a s exploratory (i.e., the resea rch ques t ions identi f ied how the mothers fed their infants ove r t ime and why they m a d e the c h o i c e s that they did). L e s s e m p h a s i s w a s p laced on quant i fy ing the foods that were fed to infants. Howeve r , detai led da ta o n dietary intake w e r e co l lec ted f rom the f a c e - to - f a c e interviews a n d this da ta is i l lustrated in a graph ic format to prov ide informat ion on dietary intake patterns over t ime. T h e s e consumpt ion patterns we re labe led a s 'high arc' curve, 'S-curve', or a 'low flat' curve (Figure 17). Approx imate quant i t ies of iron-fortified ce rea l mothers ' fed to their infants' w a s ext rapolated f rom the mothers ' retrospect ive descr ip t ions and quest ionna i re r e s p o n s e s . T h e f igure a ids in identifying, theoret ical ly, how different patterns of iron-fortified ce rea l intake might contr ibute to dietary iron a d e q u a c y f rom c e r e a l s . C lea r l y , mo re sys temat ic record ings of quant i t ies of ce rea ls a n d other so l id foods fed to infants f rom 4 - 9 months a re n e e d e d to identify if, or to what d e g r e e t h e s e 3 consumpt ion patterns reflect patterns that identify an infant's risk for dietary iron i nadequacy . 134 DISCUSSION 3 4 5 6 7 8 9 10 Infant Age (months) Figure 17. T h e p laus ib le var ia t ions in infants' iron-fortified ce rea l consump t i on patterns from 4 to 9 months of age . T h e app rox ima te quanti ty of iron-fortified ce rea l mothers ' fed to their infants' was ext rapolated f rom the mothers ' ret rospect ive descr ip t ions of food in take and ques t ionna i re responses . T h e 3 patterns a re b a s e d on in-depth interviews with a s a m p l e of 12 mothers . T h e f igure a ids in descr ib ing , theoret ical ly, how ce rea l consumpt ion patterns s u c h a s the 'low flat curve' o r the first part of the 'S-curve' cou ld inf luence d ietary iron i nadequacy in c o m p a r i s o n to the 'high arc curve' consumpt ion pattern. 135 DISCUSSION In addi t ion to the infant 's pe rsona l charac ter is t ics (i.e., temperament ) , factors related to the mother a p p e a r to de termine food a c c e p t a n c e to s o m e degree . Th is s tudy found variabi l i ty in the number and types of feed ing s t rategies u s e d by mothers . T h e ava i lab le da ta sugges t that the mothers ' sol id food feed ing behav io rs might in f luence d ietary i ron a d e q u a c y in 3 w a y s , a s s u g g e s t e d by the 3 cu rves i l lustrated in F igure 17. T h e infant so l id food feed ing strategies identif ied in this s tudy that might have determined the high arc curve inc lude appropr ia te mix ing strategies that focus on the infant's food taste and texture p re fe rences a n d swi tch ing b r a n d s a n d t ypes of ce rea l to identify the o n e s the infant l iked. Other s t rategies inc lude adjust ing the feed ing m a n a g e m e n t or adjust ing feed ing rout ines s o that so l id foods are fed dur ing the day w h e n the infant is most l ikely to be hungry, feed ing the infant dur ing fami ly mea l t imes a n d soc ia l i z ing a round food in o rder to promote posi t ive feed ing d y n a m i c s . T h e s e st rategies fit the S-curve pattern a s we l l , but the mother m a y have taken longer to learn 'how' and 'what ' to feed her infant. Fo r e x a m p l e , infant food pre fe rence c u e s m a y have been misinterpreted (delay ing the introduction of cerea ls) or learn ing how to m a n a g e dai ly feed ing rout ines m a y have taken longer. In addi t ion, if the mother u s e d mix ing s t ra teg ies that the infant d is l i ked , p rog ress o n gett ing the infant to accep t what w a s offered m a y h a v e b e e n d e l a y e d . T h e last cu rve , the low flat curve, sugges ts that the infant had not accep ted the c e r e a l s that we re of fered. T h e mothers in this c a s e might have repeated ly of fered the s a m e ce rea l that the infant d is l i ked , rather than swi tch ing to another type or b rand , or mix ing with other foods to alter the taste or texture acco rd ing to the infants' p re fe rences . T h e st rategies that did not promote i ron- fortified infant ce rea l consumpt ion inc luded repeated ly offering d is l iked food and wait ing for cerea l accep tance without tai lor ing the feed ing s t ra tegy to meet the infants' food p re fe rences . Other s t rategies that did not p romote ce rea l a c c e p t a n c e inc luded swi tch ing to fruits, vege tab les a n d s n a c k foods that the infant then a c c e p t e d , or us ing s t rategies that might c a u s e negat ive feed ing d y n a m i c s (distracting, sneak ing or camou f l ag ing foods , stuff ing or forc ing food into the mouth). In s u m m a r y , behav io ra l f o c u s e d educa t ion intervent ions that a re d e v e l o p e d with an e m p h a s i s on the types of s t ra tegies that p romote iron-fortif ied ce rea l accep tance quick ly a re lack ing . Interventions that focus on modi fy ing mothers so l id food feed ing prac t ices wou ld improve infant dietary iron intake wh ich is c lear ly important to the prevent ion of iron de f i c iency a n e m i a and iron deple t ion. Further, 136 DISCUSSION an intervent ions that f o c u s e s on 'how' to feed an infant cou ld have addit ional benef i ts to the mother s u c h a s provid ing a n i nc reased s e n s e of se l f -e f f icacy a n d con f i dence feed ing so l id foods dur ing a c o m p l e x transit ion p r o c e s s . 5.4. Study limitations Transferabi l i ty is the term u s e d , ins tead of external validity, in qual i tat ive resea rch , to desc r ibe the degree to wh i ch the resea rch f indings c a n b e app l i ed in other sett ings or other groups of peop le . T o max im ize transferabi l i ty of results, r esea rche rs state how, under what condi t ions, and from whom da ta were co l lec ted , thus a l lowing the reader to a s s e s s the degree to which the f indings might app ly to other contexts or a g e g roups (L incoln Y . S . a n d G u b a E . G . 1986). 'Thick ' , detai led descr ip t ions of the interview data and the part ic ipant character is t ics have b e e n prov ided throughout the thes is document . Th is a l lows the reader to judge the transferabi l i ty of the p resent s tudy f indings to other s i tuat ions or populat ions. T h i s s tudy used a qual i tat ive resea rch app roach to carefu l ly s tudy a sma l l number of part ic ipants. T h e s a m p l e is not representat ive of other populat ions (e.g. with different ethnic backg rounds , s o c i o - e c o n o m i c s ta tus, or l i festyles) s i n c e the s a m p l e w a s sma l l a n d w a s not se lec ted randomly. T h e s a m p l e w a s se lec ted f rom 3 locat ions in V a n c o u v e r , rather than a s ing le si te, to facil i tate part ic ipat ion of mothers f rom different locat ions. Howeve r , the mothers were relatively h o m o g e n e o u s , they were al l of C a u c a s i a n background , we re al l h ighly educa ted and most were first t ime mothers. T h e s tudy f ind ings therefore, a re l imited to the pe rspec t i ves of t hese part ic ipants and are difficult to c o m p a r e to other g roups of mothers . Mos t of the part ic ipants were int roduced to the resea rch student through a publ ic heal th nu rse . T h e nurse m a y have se lec ted mothers b e c a u s e of her prev ious exper ience with the mother 's infant feed ing pract ices and c o n c e r n s . In this way , mothers m a y have been se lec ted who had more or f ewer diff icult ies feed ing so l id f o o d s to their infants. T h e pr imary method of da ta co l lect ion w a s in - depth interviews. T h e research student had prior training in interv iewing techn iques and unders tood the impor tance of ' l is tening' to the mothers ' stor ies, not direct ing t hem. In this way , through expe r i ence and a w a r e n e s s , the potential of ' leading ' participant r esponses w a s d e c r e a s e d . T h e interv iews a l s o fo l lowed a s e m i - structured interview gu ide. T h e interviews star ted with b road , o p e n - e n d e d ques t i ons that f o c u s e d the interview onto the genera l topic. 137 DISCUSSION Th is a l lowed the part ic ipants to desc r ibe or identify infant so l id food feed ing i ssues that were important to them. Howeve r , the gene ra l top ic f o c u s e d o n infant so l id food feed ing and thus this e m p h a s i s w a s evident f rom the da ta in the t ranscr ipts on food , feed ing , and nutrition and less e m p h a s i s on env i ronmenta l i s s u e s that m a y impact mothers ' feed ing c h o i c e s . T h u s , regard less of the p rocedures in p lace to d e c r e a s e lead ing r e s p o n s e s , the resea rch focus itself and the graduate s tudent 's nutrition background potent ial ly b i a s e d the transcript da ta towards these i ssues . Further, the graduate student has young ch i ldren a n d thus h a s ex tens ive exper t i se in infant feed ing f rom feed ing her o w n infants. T h e s e persona l e x p e r i e n c e s a ided in es tab l ish ing rapport with the part ic ipants quick ly a s wel l a s a ided da ta interpretation. Howeve r , pe rsona l b i a s e s f rom the researcher ' s p reconce ived ' i deas ' about ' feeding ' m a y have in f luenced the da ta interpretat ions (i.e., diff icult ies with cerea l accep tance ) . It is important to a c k n o w l e d g e pe rsona l va lues and assumpt ions that might b ias interpretat ions but a lso br ing a un ique v iew to the data co l lec t ion a n d ana lys i s . P e r s o n a l expe r i ences feed ing chi ldren sol id foods a n d breast - feed ing beyond 9 months of a g e e n h a n c e d the researcher ' s a w a r e n e s s , knowledge a n d sensi t iv i ty to m a n y of the cha l l enges , dec i s ions and i ssues encoun te red by the mothers in this s tudy dur ing the transit ion p r o c e s s . Howeve r , due to these prev ious expe r i ences certain b i a s e s m a y have in f luenced da ta interpretat ion. P e r s o n a l b i a s e s s u c h a s the researcher ' s va lues that a re cen te red a round the impor tance of nutrition to infant heal th and ach ievemen t and the crit ical role of the mother or pr imary ca reg ive r in the infant feed ing p r o c e s s m a y have s h a p e the w a y that the da ta were v iewed and unders tood. T h e resea rche r a c k n o w l e d g e s that w o m e n ' s exper iences a n d their ' vo ice ' represents 'expert ' knowledge of the int r icacies of day to d a y tacit know ledge and hence a s s u m e d that the so l id food feed ing p r o c e s s dur ing the transit ion per iod wou ld be c o m p l e x . T h u s , qual i tat ive resea rch methods were c h o s e n to study this complex i ty . T h e resea rche r a s s u m e d that the feed ing pract ices a m o n g mothers wou ld differ b e c a u s e feed ing prac t ices wou ld be c lose l y l inked to e a c h mother 's unique pe rsona l and env i ronmenta l context . T h e resea rche r ' s role a s the pr imary d a t a co l lec t ion and ana lys i s instrument is thus, to unders tand h o w t h e s e expe r i ences might b ias the da ta interpretat ions. T h e credibi l i ty of the resea rch interpretat ions w a s e n h a n c e d through the fol lowing p rocedures . A reflexive journal w a s kept throughout the s tudy that inc luded a detai led d ia logue about the mean ings of the data that we re be ing a n a l y z e d . In - depth interv iews were comple ted with 12 mothers . T h e in - depth 138 DISCUSSION interviews, the ana l ys i s p rocedures and pro longed, intensive contact with the f ield of s tudy facil i tated the deve lopment of the concep tua l dens i ty of the f ind ings of this study. A potential l imitation of the s tudy w a s that the f ind ings a re dependen t on the part ic ipants d i scuss ing their actual bel iefs and pract ices and not what they m a y perce ive that the researcher wants to hear. T h e part ic ipants in this s tudy m a y have c h o s e n , or not, to inc lude detai ls on the diff icult ies they encoun te red , pract ices or behav io rs that m a y be cons ide red inappropr iate or their pe rsona l fee l ings (i.e., negat ive) about health pro fess iona ls ' pract ices. Howeve r , the mothers s e e m e d very comfor tab le shar ing their expe r i ences feed ing their infants and open ly ref lected on the prac t ices that did not work a s wel l a s others that d id . T h e part ic ipants a p p e a r e d to be comfor tab le with the resea rch student, a n d this m a y have been due to the fact that they all knew that the resea rch student had ch i ldren and were interested in her feed ing expe r i ences a s wel l . A l though the mothers f reely d i s c u s s e d h o w they f ed their infants, they a p p e a r e d l e s s o p e n about their fee l ings about the role of the 'exper ts ' (i.e., health c a r e pro fess iona ls ) , in the context of the so l id food feed ing p rocess . T h i s w a s poss ib ly due to their percep t ions about the confidential i ty of the da ta . A de ta i led descr ip t ion of how the ana l ys i s evo l ved , with the cod ing p rocedu res , g i ves insight into the qual i ty (dependabi l i ty) of da ta m a n a g e m e n t organ izat ion and ana lys is p rocedures . A ser ies of documenta t ion p rocedures we re fo l lowed ( L C , I ISS, MSa*, C C S S and integrative d isp lays) to aid in the d a t a o rgan iza t ion , the ana l ys i s p rocedu res a n d the d a t a interpretat ions. T h e sys temat i c d a t a co l lect ion, t ranscr ipt ion a n d ana lys i s p rocedures u s e d in this s tudy a d d to the quali ty of ana lys i s ach ieved (i.e. within and a c r o s s c a s e ana lys is ) (Rodge rs and C o w l e s , 1993). T h e interpretive ana lys is p r o c e s s was iterative in that it invo lved the writ ing of s u m m a r i e s a n d then returning to the or iginal d a t a s o u r c e to verify the evolv ing concep t s , ca tegor ies a n d t h e m e s within the original context. Howeve r , this is the research s tudent 's first major resea rch project and thus the da ta m a n a g e m e n t and da ta ana lys i s m a y reflect this lack of exper ience . Th is is a limitation s i nce , in qual i tat ive research , the da ta ana lys is tool is the researcher . S t r a u s s a n d Co rb in (1990) state that " theoret ica l sensit iv i ty refers to the attribute of hav ing insight, the abil i ty to g ive mean ing to da ta , the capac i t y to unders tand, and capabi l i ty to separa te the pertinent f rom that wh ich isn't. It is theoret ica l sensi t iv i ty that a l lows one to deve lop a theory that is g rounded , concep tua l l y d e n s e , and wel l in tegrated" . T h e s e authors sugges t 4 s o u r c e s that promote ' theoret ical sensit ivity"; the literature, p ro fess iona l exper ience , pe rsona l expe r i ence and the ability to ba lance be tween creativi ty and s c i e n c e . T h e interpretat ion of the data is a l so l imited by the 139 DISCUSSION graduate s tudent 's breadth of knowledge in the f ield of qual i tat ive da ta ana lys is methods and perspect ives . T h e da ta interpretat ions wou ld be different if a feminist perspect ive w a s u s e d in the app roach to da ta ana lys i s . Al ternately, a d i scou rse ana l ys i s wou ld have identif ied different, yet important, t hemes within the t ranscr ipts. Th i s s tudy used g rounded theory da ta ana lys is p rocedures in order to identify ' p rocess ' within the da ta ; however , it is a c k n o w l e d g e d that other perspec t ives m a y have b e e n va luab le for unders tand ing factors that de termine mother 's sol id food feed ing c h o i c e s . A further l imitation of this s tudy w a s that the part ic ipants were not g iven the opportuni ty to prov ide feedback on the da ta interpretat ions. Future resea rch n e e d s to add ress this i ssue . T h e interpretat ions of the transcript d a t a w e r e , therefore, not ver i f ied with the part ic ipants. Further, the interview d a t a co l lec t ion w a s comp le ted before the ana l ys i s was star ted. Howeve r , this m a y not be a s important in this s tudy a s in a larger s tudy w h e r e ' theoret ical ' samp l ing of part ic ipants for subsequen t interviews are b a s e d on the f indings of the p rev ious interv iews. A l though this s tudy u s e d 2 methods of da ta col lect ion ( in-depth s e m i - structured interview a n d quest ionnai re) to obta in informat ion, the quest ionnai re w a s comp le ted by on ly 9 of the 12 part ic ipants. S o m e ques t ions in the quest ionna i re had two mean ings a n d thus, the formatt ing of the ques t ions requires rev is ions . S o m e da ta w a s m i s s e d in the sp readshee t format due to the complex i ty of the answe r format (i.e., f requency of feed ing cerea ls ) a n d thus rev is ions to simpl i fy the format a re n e e d e d . Externa l c h e c k s were comp le ted dur ing the ana l ys i s of da ta by ask ing p ro fess iona l pee rs (Superv isory Commi t tee ) to read drafts of s tudy reports. Th i s a ided in 'ba lanc ing ' v iewpoints on c o n c e p t s , ca tegor ies , a n d the re la t ionships that w e r e identi f ied. T h e f e e d b a c k w a s u s e d to reconstruct interpretat ions. Howeve r , the commi t tee cons i s ted of w o m e n , da ta interpretation f eedback m a y have dif fered if the commi t tee had b e e n c o m p o s e d of m e n and w o m e n . A further limitation of this s tudy w a s that the f indings were not p resen ted to the heal th p ro fess iona ls and mothers at the recruitment s i tes . Th i s p r o c e s s wou ld h a v e a i d e d in shar ing the f indings with this group and veri fying the interpretat ions a n d their re levance to the mothers in t hese g roups . In order to keep the ana lys i s b road to identify contextua l factors or in f luences on the so l id food feed ing p r o c e s s , negat ive c a s e s of s i tuat ions, even ts , or expe r i ences were identif ied throughout the ana lys is p r o c e s s . Fo r e x a m p l e , 14 feed ing s t rategies were identif ied, rather than just a few, sugges t ing an 140 DISCUSSION in tense ana lys is of the da ta to identify the most var iat ions poss ib le . However , qual i tat ive da ta ana lys is is recogn ized a s a d e m a n d i n g cogni t ive task, thus the research students level of ' fat igue' must be acknow ledged a s inf luencing the ana lys is ou t come . T h e conf i rmabi l i ty cr i ter ia a ims to eva luate the research product, the da ta , the f indings, interpretat ions, a n d recommenda t i ons . T h e da ta ob ta ined f rom the mothers in this study w a s very ' r ich' and the s tudy f indings reflect this. T h e resul ts of this s tudy c a n be judged in light of the numerous p rocedures fo l lowed to promote the best da ta managemen t , da ta ana lys is , a n d interpretive integration poss ib le . Howeve r , the recommenda t i ons e m p h a s i z e the n e e d to val idate the t h e m e s and their p laus ib le re lat ionships in future s tud ies with larger s a m p l e s i z e s of mothers with var ied feed ing pract ices and expe r iences (breast a n d bot t le- feeding, more than o n e child) and backg rounds (ethnic, soc i o -econom ic , and lifestyle). A l though this is on ly a sma l l s tudy of mother 's infant feed ing behav io rs , the purpose w a s to invest igate behav io rs in-depth in a natural set t ing. Th i s research has ra ised s o m e important quest ions regarding dietary iron a d e q u a c y and the prevent ion of iron def ic iency a n e m i a and iron deplet ion in a natural set t ing. T h i s s tudy has a l so prov ided a concep tua l f ramework of so l id food feed ing during the transit ion p r o c e s s that cou ld be u s e d to gu ide future resea rch and pract ice. 5.5 Conclusions. Sol id food feed ing is c o m p l e x and invo lves interact ions at many levels . T h e mother 's sol id food feed ing prac t ices a re de te rm ined , in part, by the infant 's feed ing r esponses , the mother 's percept ions of infant food n e e d s a n d the mother 's know ledge and sk i l ls . P rac t i ces need to be appropr iate to meet the infant's evolv ing nutrit ional requ i rements , espec ia l l y iron n e e d s , dur ing the transit ion per iod (4 to 9 months) . It is known that by 9 months of a g e infants who are not bott le-fed with iron-fortified formula are at high risk for iron de f i c iency a n e m i a and low iron s to res . Dietary iron f rom comp lemen ta ry foods is essent ia l to prevent iron de f i c iency a n e m i a and iron deplet ion by 9 - 12 months of age , however , the content and bioavai labi l i ty of iron in so l id foods of fered dur ing the transit ion per iod is low. Therefore, it is crit ical that mothers learn 'how 1 to feed sol id foods appropr iate ly , if the infant's iron s tores are to be mainta ined dur ing this nutrit ionally 'vu lnerable ' per iod . 141 DISCUSSION The first objective of this study was to identify mothers' solid food feeding practices, focusing on what foods are fed, the quantity fed, the duration over which foods are fed, specifically iron-fortified infant cereals, cereal preparation methods, and the patterns of intake of cereals during the transition period when infants are between 4 to 9 months of age. All of the mothers in this study started the feeding process and offered iron-fortified infant cereals to their infants as recommended in the infant feeding guidelines. However, the quantity and patterns of cereal intake varied among the infants. Variations were also found in the cereal preparation methods and the number and type of feeding strategies that mothers used to feed their infants solid foods. The differences in infant cereal consumption patterns identified from the transcript data were further explored by graphing the data over time. Three cereal consumption patterns (high curve, S-curve or low flat curve) were extrapolated from this data. Future research investigating differences in cereal consumption patterns might increase our understanding of the impact of the solid food feeding process on infant iron status during the transition period. This in turn might reflect better what actually occurs during the period when the exclusive liquid diet is being gradually replaced by semi-solid foods. Possibly, tracking of consumption patterns over time could aid in identifying mothers who would benefit from guidance on strategies to promote infant acceptance of iron-fortified infant cereals. The second objective of this study was to identify why mothers feed their infants solid foods in the way that they do. The most important aspect of this research is the discovery of 5 themes that were identified as central to the solid food feeding process. These themes occur at 3 main levels - the mother, the infant, and the environment. A 3 - dimensional conceptual model of infant solid food feeding was developed to illustrate these themes. The causal-consequence model was used to build a second conceptual model. The second model links dietary iron adequacy to the plausible relationships that were identified and represented in the 5 themes. These models help identify and better understand what factors might lead to problems in dietary iron adequacy and thus provides a framework to aid in targeting solid food feeding practices that could be modified to increase dietary iron adequacy. The third objective of this study was to explore the link between the solid food feeding practices used by the study participants and current solid food feeding recommendations put forth by expert groups. This study found that mothers appear to follow the recommendation of when and what to start feeding their infants. The difficulties that mothers had feeding their infant solid foods appeared to revolve around 142 DISCUSSION 'how' to feed solid foods. Further, the mothers described learning how to feed their infants through 'trial and error'. The present research has explored how mothers feed their infants and what influences the way that they feed solid foods. This information is essential to developing effective multi-level education strategies that are aimed at improving complementary solid food feeding practices and hence, the iron intake of infants at risk. The solid food feeding models that have been developed from this research can be used to guide broader research on the determinants of solid food feeding practices. The models provide a framework of the infant behaviors, the mothers' practices, and determinants within the mothers' 'proximal' environments that influence the ability to feed solid foods, and thus, are useful for informing health care professionals working with mothers during the solid food feeding process. 143 FUTURE DIRECTIONS Chapter VI 6.1. Future directions for research 1 . Future s tud ies shou ld cont inue to exp lo re the t h e m e s , mode ls and f ramework identif ied and d e v e l o p e d in the present study. R e s e a r c h us ing focus groups is n e e d e d to verify the present f indings in a larger mo re he te rogeneous s tudy s a m p l e . 2. Future s tud ies with a larger s a m p l e of mothers cou ld be under taken to e x a m i n e sol id food feed ing s t rategies that cou ld potential ly p romote the consumpt ion of iron-fortified ce rea l in i nc reased quant i t ies, p romote a faster rate of ce rea l a c c e p t a n c e and promote max ima l potential for high iron absorpt ion (such a s the preparat ion method) . 3 . A n educa t ion intervent ion cou ld be d e s i g n e d that wou ld promote mothers ' unders tand ing of how to feed so l id foods dur ing the transit ion per iod , that wou ld promote st rategies that i nc rease the consumpt ion of dietary iron f rom iron-fortif ied infant ce rea ls and that moni tors infant iron status to determine the ef f icacy of the educat ion intervent ion. 4. Future s tud ies cou ld u s e the mode l s d e v e l o p e d f rom the f indings in the present s tudy to gu ide b roader resea rch s u c h a s identifying the impor tance of the mother 's se l f -ef f icacy to so l id food feed ing ou t comes . 144 FUTURE DIRECTIONS 6.2. Future directions for practice 1. The findings from this study suggest that the solid food feeding process is complex and factors within the mother's proximate environment influence this process. Future directions for practice could thus be to develop nutrition education tools that address the gaps in the information provided to mothers by current infant feeding resources (i.e., providing more detail on practical infant feeding issues revolving around how to feed solid foods and addressing mothers concerns). 2. In recognition that learning takes place in many contexts, it would be beneficial for future practice to explore innovative ways of facilitating dialogue and addressing mother's solid food feeding concerns and factors that determine solid food feeding success during the transition period. This may be accomplished through either utilizing the public health settings that the mothers frequently attend and/or internet technology (i.e., mother chat forums with expertise provided by nutrition experts). In this way, through a more focused approach suggested by the conceptual framework developed in the present study, health professionals working with mothers may benefit from a 'roadmap' of issues that may be important to the mother in her natural setting. 145 REFERENCES References Abrams SA, Wen J , Stuff J E : Absorption of calcium, zinc, and iron from breast milk by five to seven month old infants. Pediatr Res 1997; 41: 384-390 A C C / S C N : Fourth Report on the World Nutrition Situation. Geneva: A C C / S C N in collaboration with IFPRI (adapted from UNICEF (1998)). The State of the World's Children 1998. Oxford: Oxford University Press 2000. Akre J : Infant feeding. The physiologic basis. Bull WHO 1989; 67(supp): 1-108 Annells M: Grounded Theory Method: philosophical perspectives, paradigm of inquiry, and postmodernism. Qualitative Health Research 1996; 6(3): 379-393 B.C. Ministry of Health. Baby's First Foods. NUT031 03/96 Beard JL, Connor JR, Jones B C : Iron in the brain. Nutrition Reviews 1993; 51(6): 157-170. Beaudry M, Aucoin-Larade L: Who breast feeds in New Brunswick, when & why?. Can J Public Health 1989; 80: 166-72 Bergerman J E , Misskey ED, Thompson DA: An overview of breastfeeding practices in three Saskatchewan health regions. J Can Diet Assoc 1979; 40(3): 236-40 Birch LL, Gunder L, Grimme-Thomas K, Laing D: Infants' consumption of a new food enhances acceptance of similar foods. Appetitie 1998; 30: 283-295 Bothwell T H , Baynes RD, MacFarlane BJ, MacPhail AP: Iron requirements and food iron absorption. J Int Med 1989; 22(6): 357-65 Bothwell T H , Charlton RW, Cook JD, Finch CA: Iron Metabolism in Man. Blackwell Scientific Publications, Oxford, 1979. Bynes RD: Iron Deficiency. In Iron Metabolism in Health and Disease. Brock J H , Halliday JW, Pippard MF, Powell LW. W B Saunders, London, UK 1994 Calvo EB, Galindo A C , Aspres NB: Iron status in exclusively breast-fed infants. Pediatrics 1992; 90: 375-379 Calvo EB, Gnazzo N: Prevalence of iron deficiency in children aged 9-24 months from a large urban area of Argentina. Am J Clin Nutr 1990; 52: 534-40 Cameron M, Hofvander Y: Manual on feeding infants and young children, 3 r d ed. Oxford: Oxford Medical Publications, 1990 Canadian Paediaric Society, Nutrition Committee. Meeting the iron needs of infants and young children: An Update. Can Med Assoc J1991; 144(11): 1451-1454 Canadian Paediatric Society, Dietitians of Canada, Health Canada. Nutrition for Healthy Term Infants: Minister of Public Works and Government Services. Ottawa. Canada. 1998 Chan-Yip A, Grey-Donald K: Prevalence of iron deficiency among Chinese children aged 6-36 months in Montreal. Can Med Assoc J1987; 136: 373-378 146 REFERENCES Charlton RW, Bothwell T H : Iron absorption. Annu Rev Med 1983; 34: 55-68. Chenitz CW, Swanson JM: From Practice to Grounded Theory: qualitative research in nursing. CA. Addison-Wesley.1986 Clark LL, Beal VA: Age at introduction of solid foods to infants in Manitoba. J Can Diet Assoc 1981; 42(1): 72-78 Cohen RJ, Rivera L.L, Canahuati J , Brown KH, Dewey K G : Delaying the introduction of complementary food until 6 months does not affect appetite or mother's report of food acceptance of breast-fed infants from 6 to 12 months in a low income, Honduran population. J. Nutr. 1995; 125: 2787-2792 Cohen RJ, Brown KH, Canahuati J , Rivera LL, Dewey K G : Effects of age of introduction of complementary foods on infant breast milk intake, total energy intake, and growth: a randomized interventions study in Honduras. Lancef\ 994; 343: 288-93 Cook JD, Bothwell, TH: Availability of iron from infant food. In: Nutrition in Infancy and Childhood, ed. A. Stekel. Raven Press, New York, 1984: 119-143 Creswell JW: Research Design: Qualitative & Quantitative Approaches. Sage: C A 1994 Dallman PR: Changing iron needs from birth through adolescence. In Nutritional Anemias (Fomon, S .J . and Zlotkin, S. eds.). Nestle Nutrition Workshop Series. Raven Press, NY 1992:30:29-38 Dallman PR: Review of iron metabolism. In Filer L.J. Dietary Iron: Birth to Two Years. Raven Press Ltd., NY 1989; 63-70 Dallman PR: Iron deficiency in infants: three topics of current interest (1995). In J.G.Bindels, A . C . Goedhart and HKA Visser (ed). In Recent Developments in Infant Nutrition, 272-77. Kluwer Academic Publishers, Great Britain,1996 Dallman PR: Iron deficiency in the weanling: a nutritional problem on the way to resolution. Acta Paediatr Scand 1986; 323: 59-67 Dallman PR, Siimes MA, Stekel A: Iron deficiency in infancy and childhood. Am J Clin Nutr 1980; 33: 86-118 Davidsson L., Kastenmayer P, Yuen M, Lonnerdal B, Hurrel RF: Influence of lactoferrin on iron absorption form human milk in infants. PediatrP.es 1994; 35: 117-124 Denzin Nk, Lincoln YS: Handbook of Qualitative Research. Sage: CA, 1994 Dewey KG, Cohen RJ, Rivera LL, Brown KH: Effects of age of introduction of complementary foods on iron status of breast-fed infants in Honduras. Am J Clin Nutr 1998; 67: 878-84 Eisner EW (1991): The enlightened eye: qualitative inquiry and the enhancement of educational practice. New York: Macmillan. In Creswell JW. Research Design: Qualitative & Quantitative Approaches. Sage: C A , 1994;163 Engelmann M, Davidsson L, Sandstrom B, Walchzyk T, Hurrell RF, Michaelsen KF: The influence of meat on non-heme iron absorption in infants. Rediatr Res 1998; 43: 768-773 147 REFERENCES E S P G A N Commi t t ee on Nutri t ion. Gu ide l i nes o n infant nutrit ion: Acta Pediatr Scand 1981 (supp): 287 Fai rweather-Ta i t S J : Iron in f ood a n d its avai labi l i ty. Acta Paediatr Scand 1989 ; S u p p l 3 6 : 1 2 - 2 1 Fai rweather-Tai t S J , F o x T, Whar f G , E a g l e s J : T h e bioavai labi l i ty of iron in different wean ing foods a n d the e n h a n c i n g effect of a fruit dr ink conta in ing asco rb i c ac id . Pediatr Res 1995 ; 37(4) : 389 -394 Fi ler L J : Dietary Iron: Bir th to T w o Y e a r s . R a v e n P r e s s Ltd. , N e w Y o r k 1989 F O A / W H O Joint Exper t Consu l ta t ion Repor t . Requ i remen ts of v i tamin A , iron, folate, and v i tamin B 1 2 . F o o d a n d Nutri t ion S e r i e s 2 3 . F A O , R o m e 1988 F o m o n S . J . and Zlotk in S : Nutri t ional A n e m i a s . Nest le Nutrit ion W o r k s h o p S e r i e s V o l . 30 . R a v e n P r e s s Ltd. N e w Y o r k 1992 F o m o n S J : Infant Nutrit ion ( 2 n d de.) . W . B . S a u n d e r s , Ph i lade lph ia : 1974: 3 0 9 F o r m a n M R : R e v i e w of resea rch on the factors assoc ia ted with cho i ce and durat ion of infant feed ing in l ess -deve loped count r ies . Pediatrics 1984; 74(4 pt2): 667 -94 F o x T E , E a g l e s J , Fa i rweather-Ta i t S J : Bioavai labi l i ty of iron a s a fortificant in infant foods . Am J Clin Nutr 1998 ; 67 : 6 6 4 - 6 6 8 F u c h s G J , Farr is R P , D e W i e r M , Hu tch inson S W , Warr ie r R, Douce t H, S u s k i n d R M : Iron status and intake of o lder infants fed fo rmula v e r s u s c o w milk with ce rea l . Am J Clin Nutr 1993 ; 58 : 3 4 3 - 348 G e s e l l A , Mg F L : F e e d i n g behav io r of infants. J B Lippincott , Ph i lade lph ia : 1937 G l a s e r B, S t r a u s s A : T h e D i s c o v e r y of G r o u n d e d Theory . A ld ine Pub l i sh ing C O , C h i c a g o 1967 G l a s e r B G : Theore t i ca l Sensi t iv i ty : A d v a n c e s in the Me thodo logy of G r o u n d e d Theory . T h e Soc io l ogy P r e s s , Mil l Va l ley , C A , 1978 G o r d e n (1975) In C h e n i t z C W . , S w a n s o n J M : F r o m pract ice to g rounded theory: qual i tat ive research in nurs ing. A d d i s o n - W e s l e y , C A 1986:74 G r a n d R J , Wa tk i ns J B , Tort i F M : Deve lopmen t of the h u m a n gastrointest inal tract. A review. Gastroenterology1976; 70 : 790 -810 G r e e n L W , Kreuter M W : Hea l th promot ion p lann ing - A n educa t iona l and env i ronmenta l app roach . Mayf ie ld Pub l i sh ing C o m p a n y . Mounta in V iew , C A , 1991 G r e e n e - F i n e s t o n e L, F e l d m a n W , He ick H, L u k e B: Infant feed ing prac t ices and soc io - demograph i c factors in O t tawa-Car le ton . Can J of Public Health 1989 ; 8 0 : 1 7 3 - 1 7 6 G u p t a S B A , V e n k a t e s w a r a n R, Goren f lo D W , Ey le r A E : C h i l d h o o d iron def ic iency a n e m i a , maternal know ledge , and materna l feed ing pract ices is a high-r isk populat ion. Prev Med 1999 ; 29 : 152 -156 Hal lberg L. S e a r c h for nutrit ional con found ing factors in the relat ionship be tween iron def ic iency a n d brain funct ion. Am J Clin Nutr 1989 ; 50 : 598 -606 148 REFERENCES Hallberg L, Rossander L , Brune M, Gleerup A: Bioavailability in man of iron in human milk and cow's milk in relation to their calcium contents. Pediatr Res 1992; 31: 524-527 Hallberg L: Bioavailability of dietary iron in man. Annu Rev Nutr 1981; 1:123-147 Health and Welfare Canada. Feeding babies - A counseling guide on practical solutions to common infant feeding questions. Ministry of Supply and Services, Canada 1986 Health and Welfare Canada. Nutrition Recommendations: The report of the scientific review committee. Ministry of National Health and Welfare. Canadian Government Publishing Center Supply and Services Ottawa, Canada 1990 Heinig MJ, Nommsen LA, Peerson J M , Lonnerdal B, Dewey K G : Intake and growth of breast-fed and formula-fed infants in relation to the timing of introduction of complementary foods: the DARLING study. Acta Paediatr 1993; 82: 999-1006 Hendricks KM, Badruddin S H : Weaning recommendations: the scientific basis. Nutrition Reviews 1992; 50(5): 125-133 Henly S J , Anderson C M , Avery MD, Hills-Bonczyk S G , Potter S, Duckett LJ : Anemia and insufficient milk in first-time mothers. Birth 1995; 22(2): 87-92 Hercberg S, Galan P: Nutritional Anemias. Baillieres ClinicalHaematology\992; 5(1): 143-168 Hertrampf E, Cayazzo M, Pizarro F, Stekel A.: Bioavailability of iron in soy-based formula and its effect on iron nutriture in infancy. Pediatrics 1986; 78: 640-645 Hutchinson SA: Grounded Theory: The Method. In Munhall PL, Boyd C O : Nursing Research: a qualitative perspective. National League for Nursing Press, New York 1993: 180-212 Idjradinata P, Elliot E: Reversal of developmental delays in iron-deficient anaemic infants treated with iron. The Lancet 1993: 341: 1-4 Ingram T T S : Clinical significance of the infantile feeding reflexes. Dev Med Child Neurol 1962; 4: 159-69. Innis SM, Nelson C M , Wadsowrth LD, MacLaren IA, Lwanga D. Incidence of iron-deficiency anaemia and depleted iron stores among nine month old infants in Vancouver, Canada. Can J of Public Health 1997; 88(2): 80-84 Katcher AL, Lonese MG: Breastfeeding by employed mothers: A reasonable accomodation in the workplace. Pediatrics 1985: 73: 644-47 Kearrey MH, Cronenwett L: Breastfeeding and employment. JOGNN1991; 20(6): 471-480 Kim SK, Cheong W S , Jun Y H , Choi JW, Son BK: Red blood cell indices and iron status according to feeding practices in infants and young children. Acta Paediatr 1996; 85: 139-44 Lehmann F, Gray-Donald K, Mongeon M, Di Tommaso S: Iron deficiency anemia in 1-year-old children of disadvantaged families in Montreal. Can Med Assoc J 1992; 146(9): 1571-77 Life Sciences Research Office Rockville Pike, Bethesda, Maryland. Assessment of nutrient requirements for infant formulas. Center for Food Safety and Applied Nutrition Food and Drug Administration. Department of Health and Human Services Washington, DC. 1998 149 REFERENCES Lincoln YS: Emerging criteria for quality in qualitative and interpretive research. Qualitative Inquiry, 1995; 1(3): 275-289 Lincoln Y S , Guba E G (1985): Naturalistic inquiry. Beverly Hills, Sage C A . In Creswell, JW. Research design: qualitative & quantitative approaches. Sage C A . 1994:162 Lonerdal B, Cederblad A, Davidsson L, Sandstrom B: The effect of individual components of soy formula and cows' milk formula on zinc bioavailability. Am J Clin Nutr 1984; 40: 1064-70 Lozoff B et al: Iron-deficiency anemia and infant development: Effects of extended oral iron therapy. Journal of Pediatrics 1996; 129: 382-389 Lozoff B et al: Long-term Developmental Outcomes of Infants with Iron Deficiency. New England Journal of Medicine 1991; 325: 687-694 Lutter C K : Breastfeeding promotion: Is its effectiveness supported by scientific evidence and global changes in breast feeding behaviors? In Short and long term effects of breastfeeding on infant health, ed. Koletzo B, Hernell O, Michaelsen K. Plenum Press, NY 2000 (in press) Lynch SR: Interaction of iron with other nutrients. Nutrition Reviews 1997; 55(4): 102-110 MacLean H, Millar W: Breastfeeding in Canada: A review and update. Ottawa: Ministry of Supply and Services Canada. 1998 MacLean HM: Women's experience of breastfeeding. Toronto: University of Toronto Press, 1990 McMillan JA, Oski FA, Lourie G , Tomarelli RM, Landaw SA: Iron absorption from human milk, simulated human milk, and proprietary formulas. Pediatrics 1977; 60-: 896-900. McMillan JA, Landaw SA, Oski FA: Iron sufficiency in breast-fed infants and the availability of iron from human milk. Pediatrics 1976; 58: 686-691 McNally E, Hendiricks S, Horowitz I: A look at breast-feeding trends in Canada (1963-1982). Can J Public Health 1985; 76: 101 -7 Mead Johnson Canada: Infant Nutrition for the 90's. 1992; 2(2): 1-8 Mennella JA, Beauchamp GK: Early flavor experiences: Research Update. Nutr. Rev 1998; 56(7): 205-211 Mennella Ja , Beauchamp GK: Mother's milk enhances the acceptance of cereal during weaning Pediatr Res 1997; 41: 188-92 Merriam SB: Case study research in education: A qualitative approach. Jossey-Bass, San Francisco 1988 Moffatt MEK. Current status of nutritional deficiencies in Canadian Aboriginal people. Can. J. Phsiol. Pharmacol. 1995; 73: 754-758 Monsen ER, Hallberg L, Layrisse M, Hegsted DM, Cook JD, Mertz W, Firnch CA: Estimation of available dietary iron. Am J Clin Nutr 1978; 31:134-41 Morse JM, Bottorff JL, Boman J : Patterns of breastfeeding and work: the Canadian experience. Canadian Journal of Public Health 1989; 80:182-88 150 REFERENCES Munha l l P L , B o y d C O : Nurs ing R e s e a r c h : A Qual i tat ive Pe rspec t i ve . Nat ional L e a g u e for Nurs ing P r e s s , N e w York 1993 . N ie l sen G A , T h o m s e n B L , M i c h a l s e n K F : Inf luence of b reas t feed ing and comp lemen ta ry food o n growth be tween 5 a n d 10 months . Acta Paediatr 1998 ; 87 : 911 -917 O'Br ien M F , S te rken E , S h e a r s E : Breas t feed ing : protect ion, promot ion and support - forward to the breast feed ing s ta tement of the breast feed ing commi t tee for C a n a d a . J C a n Diet A s s o c 1998; 59(1): 10 O s k i F A , L a n d a w S A : Inhibition of iron absorpt ion f rom human milk by baby food . Am J Dis Child 1980 ; 134 : 4 5 9 - 6 0 O s k i F A : T h e c a u s e s of iron def ic iency in infancy. In Fi ler L . J . Dietary Iron: Birth to T w o Y e a r s . R a v e n P r e s s Ltd. , N e w Y o r k 1989 : 63 -70 P i cc i anno M F , Gu th re H A : C o p p e r , iron, and z inc contents of mature human milk. A m J C l in Nutr 1976 ; 2 9 : 2 4 2 - 2 5 4 P izar ro F, Y ip R, Da l lman P R , O l i va res M , Hertrampf E , Wa l te r T : Iron status with different infant feed ing reg imens : re levance to sc reen ing a n d prevent ion of iron def ic iency. J Pediatr 1 9 9 1 ; 118 : 687 -92 Pollitt E: Iron de f i c iency and cogni t ive funct ion. Annu Rev Nutr 1993 ; 13: 521 -537 P r i dham K F : F e e d i n g behav io r of 6 to 12 month o ld infants: a s s e s s m e n t and s o u r c e s of parental information. J Pediatr 1990 ; 117 : S 1 7 4 - 8 0 Promot ing b reas t feed ing : a role for the dietit ian/nutrit ionist. Off ic ial posi t ion of the C a n a d i a n Dietet ic Assoc ia t i on . J of Can Diet Assoc 1989 ; 50(4): 211 -14 R i o s E , Hinter R E , C o o k J D , Smi th N J , F inch C A : T h e absorp t ion of iron a s supp lemen ts in infant cerea l and infant fo rmu las . Pediatr 1975 ; 55 : 6 8 6 - 6 9 3 R o d g e r s B L , C o w l e s K V : T h e qual i tat ive resea rch audit trail: A comp lex col lect ion of documenta t ion . Research in Nursing and Health 1993 ; 16: 219 -226 Rossande r -Hu l t hen L, Ha l lbe rg L: Dietary factors inf luencing iron absorpt ion - an overv iew. Iron Nutrition in Hea l th a n d D i s e a s e . J o h n L ibbey and C o m p a n y Ltd. , 1996 105-115 R o s s e a u E H , L e s c o p J N , Fon ta ine S et a l : Inf luence of cultural a n d env i ronmenta l factors on breast - feed ing. CMAJ 1982 ; 127 : 701-4 S a a r i n e n U M , S i i m e s M A , D a l m a n P R : Iron absorp t ion in infants: high bioavai labi l i ty of breast milk iron a s indicated by the extr insic tag method of iron absorpt ion and by the concent ra t ion of s e r u m ferritin. J. Pediatr 1977 ; 9 1 : 36 -39 Sat ter E . T h e feed ing re lat ionship: p rob lems and intervent ions. J Pediatr 1990; 117 : S 1 8 1 - 9 S a w c h u k P , Rau l iuk M , K o t a s k a A , T o w n s e n d S , W i l s o n E , Starr M : Infant nutrition p rogram: i ron-def ic iency a n e m i a in a First Nat ions communi ty . 96 Curcumpolar Health 1996; 189-193 S c a m m o n R E , Doy le L O : Obse rva t i ons on the capac i t y of the s t o m a c h in the first ten days of postnata l life. Am J Dis Child 1990; 516 -38 151 REFERENCES Schulz-Lell G , Buss R, Oldigs HD, Dorner K, Schaub J : Iron balances in infant nutrition. Acta Paediatr. Scand 1987; 76: 585-591 Schwartz C , Evers S: Infant feeding practices in low-income communities in Ontario. J Can Diet Assoc 1998; 59 (1): 30-34 Siimes MA, Salmenpera L. Perheentupa J : Exclusive breast-feeding for 9 months: risk of iron deficiency. J Pediatr 1984; 104:196-99 Siimes MA, Vuori E, Kuitunen P: Breast milk iron - a declining concentration during the course of lactation. Acta Paediatr. Scand 1979; 68: 29-31 Smith N J , Rios E: Iron metabolism and iron deficiency in infancy and childhood. In Advances in Pediatrics, ed. I. Schulman. Year Book Medical Publishers, Inc., Chicago 1974:21:239-280 Stekel A: Iron requirements in infancy and childhood. In Iron Nutrition in Infancy and Childhood (Stekel A., ed). Nestle Nutrition Workshop Series, Raven Press NY. Vol. 4.1984:1-6 Stephen LJ , Innis SM: Complementary feeding practices: understanding the complexity of the milk to solid food transition process of mother and infant. Can J of Diet Prac and Res. 1999; Suppl.59:122 (abstr.). Stephenson DM, Meeks Gardner J M , Walker S, Ashworth A: Weaning-food viscosity and energy density: their effects on ad libitum consumption and energy intakes in Jamaican children. Am J Clin Nutr 1994; 60: 465-9 Stewart PJ , Steckle J : Breastfeeding among Canadian Indians On-Reserve and women in the Yukon and N.W.T. Can J Public Health 1987; 78: 255-61 Strauss A., Corbin J : Basics of qualitative research: Grounded theory procedures and techniques. Newbery Park, Sage, C A 1990 Streubert HJ, Carpenter DR: Qualitative research in nursing advancing the humanistic imperative. J .B. Lippincott Company Philadelphia. 1995 Sullivan S A , Birch LL: Infant dietary experience and acceptance of solid foods. Pediatrics 1994; 93: 271-277 Tanaka PA, Yeung DL, Anderson G H : Infant feeding practices: 1984-85 versus 1977-78. Can Med Assoc J1987; 136: 940-44 Underwood BA: Weaning practices in deprived environments: the weaning dilemma. Pediatrics 1985; 75(1 pt2): 194-8 Vancouver Health Department, West Main Unit: Position on infant feeding for the first year of life. November 1993 Walter T, Dallman PR, Pizarro F, Velozo L, Pena G , Bartholomey S J , Hertrampf E, Olivares M, Letelier A, Arredondo M: Effectiveness of iron-fortified infant cereal in prevention of iron deficiency anemia. Pediatrics 1993; 91: 976-982 Walter T et al: Iron deficiency anemia: adverse effects on infant pyschomotor development. Pediatrics 1989; 84: 7-17 152 REFERENCES Whalen EA, Caulfield LA, Harris SB: Prevalence of anemia in First Nations children of northwestern Ontario. Canadian Family Physician 1997; 43: 659-664 Wharton B: Weaning and child health. Ann Rev Nutr 1989; 9: 377-94 Whitehead R G : Infant physiology, nutritional requirements, and lactational adequacy. Am J Clin Nutr 1985a; 41(2 supp): 447-58 Whitehead R G : The human weaning process. Pediatrics 1985b; 75(1 pr2): 189-93 W H O International code of marketing of breastmilk substitutes. World Health Assembly: Geneva, Switzerland, 1981 W H O / UNICEF. Protecting, promoting and supporting breast-feeding: the special role of maternity services. Geneva, Switzerland: World Health Organization/ UNICEF, 1989 Williams PL, Innis S M , Vogel AMP, Stephen LJ: Factors influencing infant feeding practices of mothers in Vancouver. Can J of Public Health 1999; 90(2): 114-119 Williams PL, Innis S M , Vogel AMP: Breastfeeding and weaning practices in Vancouver. Can J Public Health 1996: 231 -36 Willows ND, Morel J , Gray-Donald K: Prevalence of anemia among James Bay Cree infants of northern Quebec. Can Med Assoc J 2000; 162(3): 323-326 World Health Organization. The quantity and quality of breast milk. Report of the W H O collaborative study on breastfeeding. Geneva. 1985 World Health Organization. Weaning from breast milk to family food. Geneva. 1988 Yeung DL: Infant nutrition: a study of feeding practices and growth from birth to 18 months. Ottawa, Ont: The Canadian Public Health Association 1983. Yeung DL, Pennell MD, Leung M, Hall J , Anderson G H : Iron intake of infants: the importance of infant cereals. CMA Journal. 1981; 125: 999-1002 Zlotkin S: Iron needs. Can J of Paediatrics 1993; (supp): 32-38 Zlotkin S H , Ste-Marie M, Kopelman H, Jones A, Adam J : The prevalence of iron depletion and iron-deficiency anaemia in a randomly selected group of infants from four Canadian cities. Nutrition Research 1996; 16(5): 729-733 153 APPENDIX A cn T3 X O x OJ s § I s cn "3 1 1 ' 3 o? ' r a I— , , C« X QO o O TI -f3 >• • * >- KJ tl Q —] S g - I n 2 re o a o 35 Ol T3 o E 8 £ o -S •a in oi S 3 o> in •— cn T3 3 & S ' J ™ o. o « t/j ^ .QJ n3 * o « -a a •» o 3 CN oj B" 3 T3 — 3 - • £ £ S in <2 ~ CN O) O T l bf)t^ .a to i >- OJ ^ TJ » i= tn 3 o ^ . 5 to •a • S . C N a. " 3 T ; -fi cn -a ™ C re U OI «  c — ra _ _ ~ QJ „• * §-° — c 10 u m Si I - fi CM £ o x 3 > 1 0 MJin cn H Is TJ TJ 01 C S P ~ u & 8 OJ X o -a c -c ra o 60 &0 OJ 01 8 c o S3 C ra ra C cn . 2 ra cn oi CD T3 c s ra Ji X O c > 'So aj X g ra 9) o .2 m .3 o . s x ra 01 c O sE 01 cn T3 a l l ra TI oi x o is d > o v*- > >. o 60 c cs "ra •El re -a X E O M) C '>> c '8 ra *—' do ra 0) u c OJ •a ra D. TJ c v I a 'X! T3 cn C oi re cn re cn re E <" Oi S E c | re & Oi X <—1 W Oi i l l 1 3 g oi * ; B . ^ i I j JCj cn- O £ 're r-'S t: 2 -a s * J B - § E | g ^ g -a H &ra o I E I i i a2 o> v C oi '5 re a. S 3, ^ ^ cn o> cn re 1 8 - 01 re 2 - g 01 Cu re no .. x Oi M > .. o QJ O O .5 S3* * (U o T3 0 u cn ; 01 cn C bO ra C 3 • - a- " * ra • s o • H i O O 60 •eSs s. , S 60 re re E ' 2 <B -a o & S Cm I, o S 5 QJ CO -2 Oi o _ 3 ra oi E O oi cn ra ^1 2 re Is w re "r" .2 S D- cn cu ~a o» ^3 tn it 6 i s c 5- ui g re O. Oi 60 c CS -a c ra cn T3 o £ . U ra ra Oi P oi cn CQ 0= 60 C a. Oi o _. E c 3 o x i cn E 8 x i .s 3 « ^>ra g "33 "O g - 3 O 01 cn re re *s i2 S 2 5 » 2 J2 c m ra 12 c - I 8^1 6 a u . g r Oi . . X X .3 > cn u _ * u o ; ^ IH _ oi > c .S-S ^ - T J D- • o g QJ o cn c ra MM " cn >. u 'ra H 3 E d. 3 S ^ x a s •a 6 • a x C cn . ra re .u O » 3 J ^ X a 3 o &" S j S 8>S -a E o c 3 o <• > 0- re cn \o •3 6b « » | - S £ 3 8.2 1 r T 2 - i •2 § s I E c =3 • c ca T f s U ra Oi g T3 £ - 1 0 c o g i i •S « c OJ |_, • — 60 3 >. Oi o x > >, re 1-S 5 1 I i x; a oi oi SB D--33-33 o Z 154 APPENDIX D Recruitment Checklist Determinants of Weaning Practices Among Breast-feeding and Formula- feeding Mothers Participant Code: • • • • Mother's name Phone Infant's name Birth date: Age:. Gestation (wks) _ _ _ _ _ Does participant meet the following criteria? O Caucasian mother who is breast-feeding or formula-feeding. O Infant is 4-12 months of age. O Mother is living in Vancouver, B.C. O Infant is born > 37 weeks gestation ) Infant has no known history of unusual feeding behavior (allergies, recurrent infections, etc.). 3 Mother has sufficient English (verbal and written) to complete interview and questionnaires. Yes • No • Initials COMMENTS: 157 APPENDIX E CD JC £ CD ~ - o o OJ CO ZJ CD O OJ LL 5 ? O ^ ~ CD E V CD £ CO c o E < CD JZ -~ >» £ o ro c c >- 9 • > E -a *t o c to .— i - Q . O '._] !c 8 ' * Q . - O S - 55 55 S O = - o J 3 O P 5? 55 g o 3 O ^ TD CD C CO O 5 o •-• •S «o O m CD CD O CD ft O CD •*= CD CO o 7- O © - c co CO u co +•> CD }2 CD > S * s S.S S -~ O Q . CO « o § .«2 § g S 13 cr  « c o -to S.r> g » g £ 1 * o tE CO a. CD o .&8 CD CO c E o > s 55 co -e TD CD co c ^ . E £ a . co • • • • • • CD •*-» CO Q «S CD '£ a) c • • • • ai TD o O c CO Q. O "t: CO Q_ Z UJ O o o ~ z CD CO < CD = 0) C _ CO O C O C D 00 x: "&0 c CD CO CD CO CO CDJtt CO CO c 158 APPENDIX E 3 o >» c o CO 3 o £ c o o GO (/> to c (0 CD cr x: F— 0) (A C o a c/> a> i — a> •*-> ro " C </> Q . a> 2™ Q . O Q . (0 c CO Ui o) a) co -q CL = _ro E .o o </> o N O CO 00 ° 0) O)(0 r: c > TJ C O 0) "fo a> x> CD CD n ; i_ C O CD •Fi CO _ a. « T3 ^ ^ ^ 2 E E < to CD CD > a) >> Xi CO X) 1— o >% GO c- < o o a • O z • co a> >- o z * 3 J ^ 0) tn Qi 3 O >» CD C T3 a) I -•—' GO CO CD o o c 3 o CD X3 < - Q >>o- CO ^ TD .C CD "O • I c E £ —' co x: - Q i £ > CO O O X -o CD < o z • CO CD > CO T3 i _ CD Q . co TJ T3 CD CD ,CD <£- i— x - CD o a. s i CD a. CD Q . •o c 2 (A CO CQ i . ffi 3 E V . o u. CN CL E w o o co E V . CD x: o o TJ 0 N , „ Q . O CO "c 3 o yo  E T3 C CD x: o* c 3 co o - c .CO C CO Q . CO £ 2 c TJ | £ (D CD O) CD 0) TD . £ *7 0> CD [_ "cO C CD CD CO CD CL 2 E « =• D 0) 3 E co s i § CO < CD < o o ca • • 00 CD <D CD CO "(0 x: CO of a> . >> 159 APPENDIX E • • • • O o c ro Q. O '•c ro o l -tn _i S o or u. CO 5 ill P C3 2 Z a z UJ LU m >- CO < m to < I to X I- z o s I o I 5 0"f • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • to a z < a: m to" LU a O) ro o T J C If) a> o <» •° =1 « TJ ~ > Q. XI O CO * i O to UJ I- p to f AM O U N TS  B ab y E at s 1.  N um be r of  f ee ds /d ay  2.  M in ut es /fe ed  BR AN D S  Yo u Us e 1.  N um be r of  f ee ds /d ay  2.  M in ut es /fe ed  i - (N n f « ID l ^ ^ t o s l 2 K LU B re as t-M ilk : In fa nt  F or m ul a:  a.  R eg ul ar  (l ow  ir on ) b.  F or m ul a w ith  ir on  ( fo rti fie d) .. c.  S oy -b as ed  fo rm ul a C ow s'  M ilk : a.  W ho le  m ilk  b.  2 %  c.  1 %  or  d.  S kim  O th er : a.  S oy  M ilk  (n ot  fo rm ul a)  b.  G oa ts  M ilk  c.  J ui ce  (d ilu tio n ) IN  H O S P IT A L  • • • • • • • • • • N E V E R  U S E D  • • • • • • • • • • 160 APPENDIX E 3 O >» o GO 3 O g o CD GO GO GO c o "GO CD 3 CT CD CD CD t_ CD O CD SZ TO « f CD CD JO CD o-X> CD l_ i_ CD o CL >. CD l_ GO CL D oe  yo u • CO m 3 O >> CD CD E E CD GO o CD CD CD XT re t TO ~. £ % CD CD X 3 CL O CD P M - - Q CL 3 O i - >?B O •»= >* >» 1? o Q C O • -2-c — GO CD CD £ O CO "° GO ° ^ 5 8*= g c r e 3 0 > ~ CD CD CD > CD o- *"' -—•. 3 0) fl) O CO - m S i l l if) co • TJ O £ 00 " > » X) CD SZ> i_ 3 O >% 00 CD i— CO CL CD CL O <: CD ca as 8 <- u. Q O i - ' O T J l f cu n >> £ c c o co 5 r 1 ' CD . CO CD <u w o c *= o o a 2 co »- O) CD C ~ CO T J a JJ> o _ a. ro Q. >- CO CD c £ ca o5 •P O) o 53 c CD CO 3,2 E . E £» CO CD 1_ CD O "CD CD O i_ 3 o 00 CD O a 8 o O) • • GO CD >- CO CD C D X 3 °P > CN O V - ' ° - GO W O CD c o .y .2 S o « 0J r- CL = O - o - co 5 . E l o $ CD CD O -O — e CD £ i t ° = $ £ CO XI O 3 5 U_ Q. £ w ai E O n at I* 11 CM ,f « f > . CO i CD C '55 3 3 O •o CD TJ CO lo * 3 o CD 00 3 3 O o TJ » co x : TJ C CO CD O C *- CD C CN CO CD CO O- Q . > 2 O Q . C 2z ° 8 TO E i f o o u. O "1.8 •2.05 .-a x : .2 6 a LU U. 00 161 APPENDIX E in o E O V w > a> c co « 16 ra w J § CO <u c (A O (A ra — (0 In ro J "to ^ T J •<- fl) 5-1 O a. • ' to 2 S 8 .2 S.'o to co 2 a> x : ^ CT w O w » >. o).E to $ fl) CD O U C I E 2 ° 2 S £ CO -o O 3 co LL, a £ TJ 0 •$> 3 o >> o •a co •a co c 8 c O .55 0 >, X) CO X) a> o TJ CD 3 . ° 3 ^ £ -g 0 O O)0J •D C > 3 CO > ~ o > to >, co in a> E CD CD o a) to CD E CD t_ O E 3 O LL C 0 °ro $ 0 a> co ta tu E >» ><>»••= c c c E '(5 « w c x > . . £ . < = CD ^ 2 LU m O o CO CO a> i o E >» c ca ra c ZJ SZ in ca a> x> "O ° o o JD in 2 CO _ _ If T J <- cu 3= LL O •2 O ~ i? E to - JO o ? £ 0) in CU s o o to ^ £ '3 CO Q) • CD C».c CD O) c T J 0 co 0 L _ 0 o E c CD CD T J CD .CD o ~ 3 o >» 2 c CO 0 x: Ti > co > a. CD xt to >, E j£ CD ra CD V— CD O XJ in CD T J a> CD .CD  JC ra >% x> ro X) >, i s ra £ CD • O - ~ s s 8 2 * - X J CD •° a? II in in i ra £ X) ro CD E TJ CD Xt ra >< X ) X ) ro ra >. >> E E o o ro "ro £ £ CD CD o o T J T J CD CD CU CD CO ro 0 > s XJ ca XJ i _ 3 O >s ro 0 t_ 0 o sz o 3 E o to 0 o c 0 3 5= C c SZ » 3 o >» o TJ ro I co 162 APPENDIX E • W H IC H  M O N TH S  H A S  B A B Y  B E E N  E A TI N G  F O O D S  O N  L IS T?  • • • • • • • • • • • W H IC H  M O N TH S  H A S  B A B Y  B E E N  E A TI N G  F O O D S  O N  L IS T?  • • • • • • • • • • ! • W H IC H  M O N TH S  H A S  B A B Y  B E E N  E A TI N G  F O O D S  O N  L IS T?  1 • • • • • • • • • • • W H IC H  M O N TH S  H A S  B A B Y  B E E N  E A TI N G  F O O D S  O N  L IS T?  • • • • • • • • • • • W H IC H  M O N TH S  H A S  B A B Y  B E E N  E A TI N G  F O O D S  O N  L IS T?  • • • • • • • • • • • W H IC H  M O N TH S  H A S  B A B Y  B E E N  E A TI N G  F O O D S  O N  L IS T?  • • • • • • • • • • • W H IC H  M O N TH S  H A S  B A B Y  B E E N  E A TI N G  F O O D S  O N  L IS T?  • • • • • • • • • • • W H IC H  M O N TH S  H A S  B A B Y  B E E N  E A TI N G  F O O D S  O N  L IS T?  • • • • • • • • • • • W H IC H  M O N TH S  H A S  B A B Y  B E E N  E A TI N G  F O O D S  O N  L IS T?  is?} Ill • • • • • • • • • • • W H IC H  M O N TH S  H A S  B A B Y  B E E N  E A TI N G  F O O D S  O N  L IS T?  • • • • • • • • • • • W H IC H  M O N TH S  H A S  B A B Y  B E E N  E A TI N G  F O O D S  O N  L IS T?  • • • • • • • • • • • W H IC H  M O N TH S  H A S  B A B Y  B E E N  E A TI N G  F O O D S  O N  L IS T?  • • • • • • • • • • CO E a £ s c I « t s llif j i l l ! ! — oi co in m i l l Q. . _ "O . to J rr o 5 d u d « ro CO jg CQ 5 I CL . . U X) 8 g | cr o 5 cd b ai co aj I I 8 r- « o_ >, 2 <n £ CD •_" i E » a> o s= X I O ro x i c i 5 < t O • • • • • • • • • • • • • • • • • • 163 APPENDIX E 3 O >. CZ o GO 3 O £ c g o cu 00 00 00 c o w * 5 0) 00 o CD +3 3 O cr co O Q. I- o> I'l If CO 3 cu a o "ro CO i _ "C CD a o o i - Q. 5 « E c < CO *2 CD CO ra .£ CD ~ 3 I Q. a X i = co ca 3 | CD O- <£ O O 3 C != O O EL5* t> J s co in a. c O CD « co Lt a5 >^-£; - T J > _ cl , o CD CD O >•> CD ra x: S — > CD 2 > O £ O CO CD f i CD 3 O >» ZJ w -Q ro >> 9 co CD 3 O 00 > , 3 XI - i CO a. o <D CO 0) co n o SZ CD CD CD GO CO >» co co * CD <: 8 2=5 O ca CD CO CD c o Q O CO t_ CD Q. CO o ci) CD CD o CO CO o CD SZ 3 O o ~— >,o- o a) XJ E CD CD O x: o 3 E a> sz CO CD CD C L CD ^ C L ~ > > C - * CD CD *- 1^ CO -.= in TJ 8 i 00 >» ro SZ o ct^ C D O 3 X Q. LO O co 2 Q- 00 CO ̂  < O CO , | o CD C L in _co CO CD CD CD .E O "3 C 2 Is CD >» 00 »t- C0 O SZ 2 ro 3 CL a. (/) 3 CD O oo >»TJ O O Q £ CN O CL Q. O f • 2 CD C D > - ro £̂ 3 CO 00 CD = c5 32 o 2 >» x: x) ,9. 0 5 JO X ) O CD x: £ 02 co £ CD . £ CD §1 > C L CD o tz .CO o c W CD CL W C JO SZ o 2 .4= 3 o CL CD _ CL C; 0) CD CO o E w o ft= >> o 5 C L Q oo >> XJ ro 3 O >» CO TJ O JO ro 2 oo CD a o >- ro 2 CD o <*— o CD Q. 4 * T J C co T J C CO l _ X J CD a> 10 o o JZ u 3 o o x : CO CD O c CD 3 C CO O 3 O >» %% It o 164 APPENDIX E CO CD i _ CD >» CO JO CD co o -° o I? >% CD -O JC _ o 3 JO >> CD CO JZ CD CO s i • O Z • CO CD 3 O >» o CO . 2 % -!=• CD g l CD C .CD 3 O >, CD _Q " l _ O CO CD 32 Q. 3 s- o co £ w I-8 X X ) 3 O x i CO CO c o c CD * - > to JS >, => s O -Q > » 1- a i • o • CO CD >- to Q CO Q Q oo Q CD CO CD CD > CD >. XI CO -O t_ o >* CO CD O Q CO CD • CO 2> 0) o >% CO _ o CO Z CD E E o o • CO CD >- o "o CD Q. CO & CD Q. >» JO CO -O 1 _ O CO >» CD CO ^ CD *2 O >< Q £ • 2 • to CD o >. "aj ' i _ CO > CO CD >, JO CO JO I c - to co CD CD Q o • o • to a) >- Ĉ - _CO .is- CO CD C — CO IT S" « Q. »»- 5 ° o | co ° CD 5= O CD O E • • CO CD >- CM Q CO Q Q 165 APPENDIX E Please give an appropriate response. The questions in this section focus on information you may have received or obtained yourself during your baby's first year. E1. Did you receive information on E2. Did you seek information yourself introducing solid foods to your on introducing solid foods to your baby? baby? ^ Yes D NO D -gotoE3. ^ Yes D NO D -gotoE3. E1a. Describe what information you E2a. Describe what information you received. sought. E1b. When did you receive E2b. When did you seek information? information? E1c. Where were you given E2c. Where did you seek information? information? E1d. Did the information you received E2d. Did the information you obtained influence your feeding practices? influence your feeding practices? Yes • No • Yes • No • E1e. What information from above did you find most helpful (if any)? Sources: Why: E1f. Was the information you received adequate for your needs? Yes • No • E3. What information would you have liked? (if any) E2e. What information from above did you find most helpful (if any)? Sources: Why: E2f. Was the information you obtained adequate for your needs? Yes • No • Please give an appropriate response. The questions in this section focus on other solid food feeding practices. F1. Has your baby been introduced to the following foods (Put yes or no in space). Fruits Egg Cheese(s) Vegetables Yogurt(s) Meat(s) F2. If you have NOT given your baby foods from the above list, comment in the following chart when you intend to introduce these foods (if you do). FOODS FROM LIST AGE OF INTENDED INTRODUCTION 166 APPENDIX E • • • • O c TO Q. 0 •E TO CL CO a z < m co" LU a re o _ c CO 0) X o x> B TO CU %n a5 a TO cu TO o LU X o a a> • W H IC H  M O N TH S  H AS  B A B Y  B EE N  E AT IN G  F O O D S O N  L IS T?  H •-.-<< -V -r.ryi, M • • • • • • • • • • • • W H IC H  M O N TH S  H AS  B A B Y  B EE N  E AT IN G  F O O D S O N  L IS T?  • • • • • • • • • • • • W H IC H  M O N TH S  H AS  B A B Y  B EE N  E AT IN G  F O O D S O N  L IS T?  • • • • • • • • • • • • W H IC H  M O N TH S  H AS  B A B Y  B EE N  E AT IN G  F O O D S O N  L IS T?  .:' ; -» • §11 • • • • • • • • • • • • W H IC H  M O N TH S  H AS  B A B Y  B EE N  E AT IN G  F O O D S O N  L IS T?  • • • • • • • • • • • • W H IC H  M O N TH S  H AS  B A B Y  B EE N  E AT IN G  F O O D S O N  L IS T?  •.>~ yyi ••• V ', • • • • • • • • • • • • W H IC H  M O N TH S  H AS  B A B Y  B EE N  E AT IN G  F O O D S O N  L IS T?  • " -v, -1 • rZ\ • • • • • • • • • • W H IC H  M O N TH S  H AS  B A B Y  B EE N  E AT IN G  F O O D S O N  L IS T?  .„-.JS> # ^ • • • • • • • • • • • • W H IC H  M O N TH S  H AS  B A B Y  B EE N  E AT IN G  F O O D S O N  L IS T?  • • • • • • • • • • • • W H IC H  M O N TH S  H AS  B A B Y  B EE N  E AT IN G  F O O D S O N  L IS T?  • • • • • • • • • • • • W H IC H  M O N TH S  H AS  B A B Y  B EE N  E AT IN G  F O O D S O N  L IS T?  , i j 1$ • • • • • • • • • • W H IC H  M O N TH S  H AS  B A B Y  B EE N  E AT IN G  F O O D S O N  L IS T?  • • • • • • • • • • • AM O U N TS  Ba by  E ats  BR AN D S  Yo u Us e 1. St ra ine d 3. Ju ni or  4.  To dd ler  1 F ru its : V eg et ab le s:  C om m er ci al  M ea t P ro du ct s:  a.  B ee f; b.  b ee f c om bi na tio ns  . . C.  P or k;  d . po rk  c om bi na tio ns .. e.  C hi ck en ; f. co mb ina tio ns  o f. . H om em ad e B ab y Fo od s:  a.  B ee f, sp ec ify  b.  P or k,  s pe ci fy  O th er : a.  F ish ; b.  C o n g e e .. .. .. . c.  E gg  (W ho le /Y ol k/ W hi te )..  d.  Y og ur t; e.  C he es e , W H A T  IS  B A B Y  E A T IN O  N O W ?  • • • • • • • • • • • N E V E R  E A T E N  • • • • • • • • • • • 167 APPENDIX E c o P ? O 3 o >» « f 3 O co >-> W) E .5 > « a. e E ° • S cw cu r E g, ~ « ^ s o o a. .s .£ 3 O cn c o •c cn O 3 cr S T3 5 c o o a. oo c c o o cn C o •c cn u 3 cr I o .2 (O .fi u > o 3 O u oo u o •s cn CN 168 APPENDIX F Determinants of Weaning Practices Among Breast-feeding and Formula- feeding Mothers in Vancouver. PARTICIPANT CODE INTERVIEW Day Month Year BABY'S BIRTH DATE Day Month Year BABY'S SEX BABY'S GESTATION AGE BABY'S BIRTH WEIGHT/LENGTH/HEAD CIRC. / / Information obtained from the demographic and infant feeding practices questionnaire will assist us in targeting infant nutrition programs more effectively. Although we greatly appreciated your participation, participation is voluntary and you do not have to answer any question(s) you do not wish. 169 APPENDIX F SECTION A - FAMIL Y BACKGROUND INFORM A TION Please Check the Appropriate Response 1. I am the baby's: CU Mother LZ] Father Relative • Nanny Other (specify) What is your age? < 20 years 20-24 years 25-29 years 30-34 years 35+ years Baby's mother • • • • • Baby's father • • • • • What is your present living status? (You may check more than one) Living alone • Living with spouse/partner • Living with family or relatives • Living with friends 170 APPENDIX F What is your marital status? (check only one) • • • • • Legally married/common-law Separated but still legally married Divorced Widowed Never married (single) 5. How many children, in total live in the household? Please check the highest level of schooling that you have completed. Mother Father Secondary (high) school? Community college, technical or vocational training University Graduate degree Some Completed • • • • • • • • Some Completed • • • • • • • • Other training? (specify) • • • • 7. What is your usual occupation? Mother Father 171 APPENDIX F 8. If you are on maternity leave, how long do you have? 9. How old will your baby be when you go back to work? 10. Which of the following describes your family income per year? • Less than $10,000 • • • • • • • $10,000 - $19,999 $20,000 - $29,999 $30,000 - $39,999 $40,000 - $49,999 $50,000 - $59,999 $60,000 - $69,999 $70,000 - over 11. Were you born in Canada? Mother Yes • No (please state country of birth) Father D Yes No (please state country of birth). 12. How many years have you lived in Canada? Mother yrs Father yrs 13. What language is spoken most often at home? i) English CU ii) French ii) Other specify : 172 APPENDIX F 14. Canadians belong to many ethnic or cultural groups. To which ethnic or cultural group(s) do you belong (please consider your usual social/cultural practices)? Mark or specify more than one, rf applicable. Please answer for mother and father of the child as applicable. Child's Mother Child's Father British, • • specify country ; French, specify . European, specify country First Nations, specify Asian, specify country Latin American, CD L—I specify country Arab, • • specify country _ Canadian, • D specify Other, • D specify ; 173 APPENDIX F 15. Are you: (Mark or specify more than one, if applicable) Child's Mother Child's Father Chinese • • South Asian (East Indian, Punjabi, Sri Lankan, Pakistani, etc.) South East Asian (Filipino, Indonesian, Laotian, Vietnamese, etc.) White/Caucasian (European, etc.) Other - Please specify, 16. Canadians often have food related practices and beliefs about food which are associated with a particular ethnic or cultural background (s). Which ethnic or cultural background(s) do you associate your usual food related practices with? For example: Western/North American, British, Vietnamese, Chinese, Mediterranean, Hindu, Moslem, Sikh, etc. 174 APPENDIX F 17. Do you exclude any of foods from your family diet? 18. Mother LZ] No Father • No EH Yes, specify below • Yes, specify below • Beef • Vegetables • Pork • Fruit • Poultry • Breads/Cereals • Fish • Pasta • Eggs • Rice • Dairy products • Beans, peas or lentils • Nuts, seeds or peanut butter Comments Does your family have any particular diet practices for medical, religious, or other reasons? Yes (please describe below) No n Comments 19. Does your baby go to play group, babysitter's home, day care centre or nursery school once a week or more? Yes if yes, specify days per week No hours per day number of children who attend with your child Thank you for your time and cooperation in completing this questionnaire. 175 APPENDIX G High cereal consumption pattern >% CD CD ro i _ CD c • mmm ~u CD TJ O O O CO Number 5 (9 MONTH OLD FEMALE) % cup [dry] ^ * 2/day + V4 cup fruit/d —. ^ 1/3 cup ^ [dry]/day 1/3 cup of each/d a1&2; C •** (Klrgjar) ©? . ' © ® ®/(D? (1)^ ®a1-2 Tbsp. = t, d =f;d = t d •••a 1&2; c (1/2 small Jar) 4 5 6 7 Infant age (months) 8 Number 8 (71/2 MONTH OLD MALE) ng  s tr at eg y  (2X5X32.^y 2 cup [dry] 2/day=1cup ng  s tr at eg y  ^ ® ® 4 T b s p . / / [dry] 2/day ^ / gr(7X |XD®c 1jar F & V each/d S o lid  f o o d  f ee d i (Ti * / I " (2X6X1) 2T#sp.[dry] 2/day - © ® . » S o lid  f o o d  f ee d i © © - ^ • ^ x f sf; d 3 4 5 6 7 Infant age (months) 8 9 D 5 176 APPENDIX G High cereal consumption pattern Number 9 (81/2 MONTH OLD MALE) » D " % ( 6 ) 3 / 4 cup at eg y 3 / 4 cup [wet] 2/day © , ® ( D 3 / 4 c u p [wet] 3/day A lll N V P  d fo o d  f ee d in g  s tr  j * • * ( D ® c • ^ ( 9 ) ® c ~ 1 jar 3/day O F C E R E A L I 4 C U P  1/ d fo o d  f ee d in g  s tr  CO (i) CO® X' ^ (Da; c 1 / 3 jar/day / * C O N SU M ED  i C U P • • • • • = d P E R D  :3 tb sp s. o - C > a 2 ; b; d P E R D  :3 tb sp s. 3 4 5 6 7 8 9 > -< Infant age (months) 177 APPENDIX G Medium cereal consumption pattern S ol id  f oo d fe ed in g st ra te g y  Number 1 (71/2 MONTH OLD MALE) -Q U A N TITY  O F C E R E A L C O N S U M E D  P E R  D A Y  1/ 2  C U P %  C U P  O tbsps. S ol id  f oo d fe ed in g st ra te g y  -Q U A N TITY  O F C E R E A L C O N S U M E D  P E R  D A Y  1/ 2  C U P %  C U P  O tbsps. S ol id  f oo d fe ed in g st ra te g y  * (V4 cup [dry] 2/day 1 Mixed with !4 jar fruit or Veg.) / / t '"• -Q U A N TITY  O F C E R E A L C O N S U M E D  P E R  D A Y  1/ 2  C U P %  C U P  O tbsps. S ol id  f oo d fe ed in g st ra te g y  / / / -Q U A N TITY  O F C E R E A L C O N S U M E D  P E R  D A Y  1/ 2  C U P %  C U P  O tbsps. S ol id  f oo d fe ed in g st ra te g y  ® b ®-—"® -Q U A N TITY  O F C E R E A L C O N S U M E D  P E R  D A Y  1/ 2  C U P %  C U P  O tbsps. S ol id  f oo d fe ed in g st ra te g y  3 4 5 6 7 8 9 Infant age (months) -Q U A N TITY  O F C E R E A L C O N S U M E D  P E R  D A Y  1/ 2  C U P %  C U P  O tbsps. S ol id  f oo d fe ed in g st ra te g y  Number 2 (9 MONTH OLD MALE) -Q U A N TITY  O F  C E R E A L C O N S U M E D  P E R  D A Y  Vz C U P  V* C U P O tbsps. S ol id  f oo d fe ed in g st ra te g y  -Q U A N TITY  O F  C E R E A L C O N S U M E D  P E R  D A Y  Vz C U P  V* C U P O tbsps. S ol id  f oo d fe ed in g st ra te g y  • -1/2 cup X [wet]; 2/day) ' / -Q U A N TITY  O F  C E R E A L C O N S U M E D  P E R  D A Y  Vz C U P  V* C U P O tbsps. S ol id  f oo d fe ed in g st ra te g y  -Q U A N TITY  O F  C E R E A L C O N S U M E D  P E R  D A Y  Vz C U P  V* C U P O tbsps. S ol id  f oo d fe ed in g st ra te g y  ±* - - -® ® •<§) ' (Da (Da (3XD © ®a =? =d A b ; d > b ; d -Q U A N TITY  O F  C E R E A L C O N S U M E D  P E R  D A Y  Vz C U P  V* C U P O tbsps. S ol id  f oo d fe ed in g st ra te g y  3 4 5 6 7 8 9 Infant age (months) -Q U A N TITY  O F  C E R E A L C O N S U M E D  P E R  D A Y  Vz C U P  V* C U P O tbsps. 178 APPENDIX G Medium cereal consumption pattern Number 4 (71/2 MONTH OLD MALE) i ih. so c d fe ed in g st ra te gy  ^ ® (-2 Tbsp. [dry] 3/day) AN TITY  O F C ER EAL C O N SU M ED  PER  I 4 CUP Vi CUP <3tbsps. d fe ed in g st ra te gy  / *° / / / / AN TITY  O F C ER EAL C O N SU M ED  PER  I 4 CUP Vi CUP <3tbsps. So lid  fo o Jji y Jgsrtiy'a'Jya (Jisp. J/a) ^ ^ \ & ® ^ ' (1.^-4) © IZ ia^a" * =f sf, d -••b;d -$-b;c?; d (6-7 bites) AN TITY  O F C ER EAL C O N SU M ED  PER  I 4 CUP Vi CUP <3tbsps. So lid  fo o 3 4 5 6 7 8 9 Infant age (months) u > -< Number 6 (-8 M O N T H O L D MALE) i fp. O d fe ed in g st ra te gy  4|^MTbsp.[dry] 2/day~ j (in last week) / / A N TITY  O F C ER EAL C O N SU M ED  PER  f 4  C U P  V i C U P  O tb sp s. d fe ed in g st ra te gy  2-3Tbsp.[dry] 2/day ^ • • A N TITY  O F C ER EAL C O N SU M ED  PER  f 4  C U P  V i C U P  O tb sp s. So lid  fo o<  J E ^ . - ^(1)3 ice cubes/day - ^ " ^ © . . «-J^ ® © @ ® ® """"" ®ltsp./d to 2 tsp./day ® a1; b; d (2 ice cubes /wk Mixed 1:4 with veg.) A N TITY  O F C ER EAL C O N SU M ED  PER  f 4  C U P  V i C U P  O tb sp s. So lid  fo o<  3 4 5 6 7 8 9 Infant age (months) > -< 179 APPENDIX G Medium cereal consumption pattern >* CD CD -+-> 2 •*-> to CD C m_m T J <D £ T J O O o CO Number 7 (71/4 MONTH OLD MALE) ^( l )2Tbop . [dry ]2 /day ® ® a 1cube veg. 2/day © © © ® ^ ' ^ a 2 ; b ; d 9 ^ * a i ; b; d (mixed with cereal) 5 6 7 Infant age (months) 8 CD CD ro o co Number 10 (7 MONTH OLD MALE) "J/j ^ ® 5 - 6 Tbsp.[dry]/day CD / „ T J / CD / (7X8) MTbspVday / (7X8) "§ 1 T3X§) -$-a2; b;d 3 4 5 6 7 8 9 Infant age (months) 180 APPENDIX G Medium cereal consumption pattern Number 12 (7 MONTH OLD FEMALE) t D C at eg ] ^3XDy, cup [wet]/day / O —1 S 3 mmm -i-> </> / / O TI d  f ee d in g  / o m d  f ee d in g  [wet)/day | sm. jar/day ® From 2tsp. banana to % banana ' plus % sm. jar fruit 3/week R EAL C O N SU M ED  P E I V* C U P  O tb s p s . o lid  f o o  ® ®2tspVday =f d =f d R EAL C O N SU M ED  P E I V* C U P  O tb s p s . CO 3 4 5 6 7 8 9 a Infant age (months) 181 APPENDIX G Low cereal consumption pattern >* O) <D *-» 2 m c • • • • 73 £ TJ O O o CO Number 3 (8 MONTH OLD MALE) -i> y (Z)a / (Da © 5 6 7 Infant age (months) 8 Number 11 (7 MONTH OLD FEMALE) >» D) 0 +•» (0 i _ 0) D) C • • • • T3 £ TJ O O O CO ® 2+ ice cubes size at lunch, up to 5 for dinner/day of vegetables CD/®? @/(gr? -N)/©? s d ^ a 2 ; b;d @ 2 14-3 Tbsp. [wet]/.day or Vi cup fr. © / © ? 5 6 7 Infant age (months) 8 182 APPENDIX H The feeding strategies/techniques that mothers appeared to use in order to promote solid food acceptance. "The actual feeding process itself is going quite well. We feed (baby) when we eat. And we pull his high chair right up with us...and between when we are cutting our own food and feeding ourselves he's eating, you know; we are dealing with him. Yeah, and I think thafs also...made it easier... for him to eat. Like before, when you're just sitting there and you are just spooning it into his mouth, he's kind of like, what's this all about. Whereas... we'll stop and we will say, "see (baby), you chew" and talking to him, and he is watching what you are doing....I have found that, umm you know, there may have been times where maybe if I am giving him lunch and I am not really having my lunch he doesn't eat as much and so I'll grab an apple and I'll start eating a apple and he'll eat more and he will continue eating so. Yeah, and also he'll, umm I start just feeding him and he'll kind of, he'll stop and he'll start fussing and if I give him a spoon so that he holds onto a spoon he'll eat...more. He'll start eating again...so I'll hold onto the dish and he'll whack his spoon into the dish...and I will give him the lid (Tuppaware containers) and so he likes either chewing on the lid or he likes putting the lid on the dish. He'll put it on and watch it fall off and put it back on again and in between I am still (she gives cues as if feeding).. .And ifs distracting...but the distracters are related to the food. The spoon and the lid for the dish... Yeah yeah and the spoon, he will chew on the spoon as well. ...And then, you know, in between, then I am putting my spoon in his mouth and he is getting the food that way and I think it helps because he is teething as well, so it helps that he's got something to chew on, for his teething. But really the way he plays with the spoon in the bowl, he's like, ifs more like he's got some control over what's happening to him. You really can see that...And I let him play with the food with his fingers and I let him touch the food but my husband doesn't. My husband is much cleaner. You can tell who has fed him. And then at the end of it, I give umm a facecloth, a wet facecloth and I put it in front of him and he always grabs it and starts chewing on it. So he kind of partly wipes his own face, because that was a real bit of a battle at first to try and wipe his face and then I realized... he kind of plays with it for a while and then I go back and tidy up (6-706-778)". 183 APPENDIX I Summary of individual solid food feeding strategies between the mothers. 0001 MED 0002 MED 0003 LOW 0004 MED 0005 HIGH 0006 MED 0001 1- lnitally 'give in' and BF 2- Trying to stuff in his mouth 3- Switched to oat 4- Mixed with fruit and later Vegetables. 5- Limited the Breastfeeding Outcome: 0002 2-1.'Give in' and breastfeed 2- lnitially pry with spoon (1169) 3-Swilched to bariey & oat which he loved 4- Now he has his food toys Outcome: 0003 3-1 .Offering one food/ time 2.Mixmg with fruit/vegetable after 6 mo. 3- Switched to Earth's Best @ 7mo Outcome: 0004 4- 1 Switching types and brands (/Milupa) 2- Mixing with juice then Juice + fruit 3- 'Giving in' (sweeter foods) 4-Give Vegetable. &/or Combination first 8tsp. ...fed up...then give cereal mixture 5- Now feeding when we eat = Socializing "family meals" Outcome: 0005 5- 1-No morning bottle. Cereal fed first 2- Mixing meats in a lot of vegetables 3- Buying a combination meat or make own (switching) 4- Addmg butter/cheese to potatoes Outcome: 0006 6- 1-Fed cereals and vegetables on back for first month 2- Hold back on fruit (tart/rash) 3- Mashed/pureed/really have to mix it (meat) with vegetables 1:4 ratio (homemade)=thinned 4- Use of abstracters (toys) related to the food 5- Famify meals 6- Partent(s) eating when feeding LS-Role Modeling-Mimicking 7- Giving control (spoon/lids etc) LS- Engaging infant in eating process. Outcome: 0007 MED 0008 HIGH 0009 HIGH 0010 MED 0011 LOW 0012 MED 0007 1- Tried cereal at 3 mo. Stopped. Fed on a regular basis at 6 mo. (Sporadic versus Routine Feeding) 2- Coordinate 'feeding' (good mood/ sit still, space between meats) 3- too difficult...so give a bottle... get him focused on eating., wants to play 4- Strapping into car seat/high chair to feed bottle 5- Food abstracters (toys) Outcome: "worried". No weight gain in -2 months 0008 1- Make Pablum thick and lumpy 2- Routme Feeding 3 meal/day (more content) 3- Not introducing Finger foods (Fear of Choking) Outcome: 0009 1- Mixing cereal + formula quite dry, feed vegetables on the side 2- Feed when baby is hungry. No set schedule flexible (4:30-7pm) 3- lf he likes something we go with it 4- At first he spit it out (cottage cheese)...Just kept putting it back in 5-Follow his lead. LS-Mother responds Outcome: 0010 1- Switching types (Milupa Mixed) 2- Make Home Made Food 3- Figure out if hungry or just doesn't like what we are giving 4- Being more creative...Hiding dislikes with likes "sneaking" 5- Eating with infant = eating together when baby eats. Routine family Meals (relaxing) 6- Play with food Outcome: 0011 1- Mixing cereal with formula 2- Feed cereal before bottle in the morning and then hold back bottle if infant doesn't eat enough cereal Outcome: 0012 1-Switching brands/types of cereal 'Outcome: "fight it" up until a month ago/not interested between 41/2 and 6 months, "worried" No weight gain for -2 months Low/Med ium/H igh indicates the infant's level of cereal intake identified from the transition graphs 184

Cite

Citation Scheme:

    

Usage Statistics

Country Views Downloads
China 3 54
Japan 3 0
Poland 1 0
United States 1 1
City Views Downloads
Tokyo 3 0
Beijing 2 0
Warsaw 1 0
Shenzhen 1 54
Ashburn 1 0

{[{ mDataHeader[type] }]} {[{ month[type] }]} {[{ tData[type] }]}

Share

Share to:

Comment

Related Items