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

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D E T E R M I N A N T S O F M O T H E R S ' SOLID F O O D F E E D I N G P R A C T I C E S DURING T H E TRANSITION PERIOD ( 4 - 9 M O N T H S O F A G E ) : IMPLICATIONS F O R IRON NUTRITION By Loraina Stephen B S c , The University of British Columbia, 1994  A THESIS SUBMITTED IN PARTIAL F U L F I L L M E N T O F THE REQUIREMENTS FOR THE D E G R E E OF MASTER OF SCIENCE In T H E F A C U L T Y OF G R A D U A T E STUDIES Department  of  Food,  Nutrition  and  Health  (Human Nutrition)  W e accept this thesis as conforming to the required standard  October  2000  T H E UNIVERSITY OF BRITISH COLUMBIA © Loraina Stephen 2000 n  In  presenting  degree freely  at  this  the  available  copying  of  department publication  of  in  partial  fulfilment  University  of  British  Columbia,  for  this or  thesis  reference  thesis by  this  for  his  and  scholarly  or  thesis  study.  for  her  of  FLi  The University of British Columbia Vancouver, Canada  DE-6  (2/88)  htiv\  gain  the  shall  requirements  agree  that  agree  may  representatives.  financial  iVuifTJ  I  I further  purposes  permission.  Department  of  be  It not  that  the  Library  by  understood be  an  allowed  advanced  shall  permission for  granted  is  for  the that  without  make  it  extensive  head  of  copying my  my or  written  ABSTRACT ABSTRACT S o l i d f o o d f e e d i n g is c o m p l e x a n d i n v o l v e s interaction at m a n y l e v e l s . S o l i d f o o d f e e d i n g p r a c t i c e s a r e d e t e r m i n e d , in part, by the m o t h e r ' s p e r c e p t i o n s of infant f o o d n e e d s , the infant's f e e d i n g r e s p o n s e s , a n d t h e m o t h e r ' s k n o w l e d g e a n d s k i l l s . It is k n o w n that b y 9 m o n t h s of a g e infants w h o a r e not bottle-fed with iron-fortified f o r m u l a a r e at high risk for iron d e f i c i e n c y a n e m i a a n d low iron s t o r e s . D i e t a r y iron f r o m c o m p l e m e n t a r y s o l i d f o o d s is e s s e n t i a l to prevent iron d e f i c i e n c y a n e m i a a n d iron d e p l e t i o n in t h e s e infants b y 9 - 12 m o n t h s of a g e . H o w e v e r , the content a n d bioavailability of iron f r o m s o l i d f o o d s offered d u r i n g t h e transition p e r i o d is low. B e c a u s e of this, it is critical that infant f e e d i n g p r a c t i c e s a r e a p p r o p r i a t e to m e e t the infant's e v o l v i n g nutritional r e q u i r e m e n t s , e s p e c i a l l y iron n e e d s , d u r i n g t h e transition p e r i o d (4 to 9 m o n t h s ) . T h e s u c c e s s of infant f e e d i n g r e q u i r e s that m o t h e r s l e a r n both what a n d h o w to f e e d solid foods. T h e p r e s e n t r e s e a r c h u s e d a g r o u n d e d t h e o r y a p p r o a c h a n d in-depth interviews with 12 m o t h e r s to e x p l o r e h o w m o t h e r s f e e d their infants a n d w h a t i n f l u e n c e s t h e w a y t h e y f e e d s o l i d f o o d s d u r i n g the transition p e r i o d ( 4 - 9 m o n t h s ) . T h i s r e s e a r c h identified 5 t h e m e s that a r e central to infant s o l i d f o o d f e e d i n g - the feeding feeding,  gaining  expertise  a n d tailoring  process,  the transition  perceiving  process.  infant food needs,  ways  of  T h e central t h e m e that h a d the  m o s t influence o n t h e s o l i d f o o d f e e d i n g p r o c e s s w a s h o w m o t h e r s w e r e 'tailoring' t h e transition p r o c e s s . A 3 - d i m e n s i o n a l c o n c e p t u a l m o d e l of infant s o l i d f o o d f e e d i n g w a s d e v e l o p e d to illustrate the interaction b e t w e e n the t h e m e s . A c a u s a l - c o n s e q u e n c e m o d e l w a s u s e d to build a s e c o n d c o n c e p t u a l m o d e l to link dietary iron a d e q u a c y to t h e p l a u s i b l e r e l a t i o n s h i p s that w e r e identified f r o m the 5 t h e m e s . F i n d i n g s f r o m this s t u d y p r o v i d e information n e e d e d for future d e v e l o p m e n t of effective multilevel e d u c a t i o n s t r a t e g i e s that a r e a i m e d at facilitating health p r o f e s s i o n a l s ' p r a c t i c e s a n d m o t h e r s ' l e a r n i n g a b o u t t h e f e e d i n g p r o c e s s a n d c o n d i t i o n s within the p r o x i m a t e e n v i r o n m e n t that d e t e r m i n e infant f e e d i n g c h o i c e s a n d i m p a c t o n the d i e t a r y intake of y o u n g infants.  TABLE OF CONTENTS  TABLE OF CONTENTS ABSTRACT  ii  TABLE OF CONTENTS  iii  LIST O F T A B L E S  vi  LIST O F F I G U R E S  vi  LIST O F A P P E N D I C E S  vii  ACKNOWLEDGEMENTS  viii  INTRODUCTION  1  1.1  Study purpose  3  1.2  Study objectives  3  LITERATURE 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  1.  2.  2.3.  3.  Infant feeding guidelines  21  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 OF CONTENTS 3.4  3.5.  4.  Interview data management and analysis  35  3.4.1.  Transcription from original data source  35  3.4.2.  Data analysis  35  Questionnaire analysis  44  RESULTS  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.  4.5.  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 'hunger  65  1  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 4.6.  4.7.  4.8  .88  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  4.6.4.  Learning through trial and error..  ....95 98  Tailoring the transition process  101  4.7.1.  The causal-consequence model  101  4.7.2.  Dietary intake patterns  108  Questionnaire  115  iv  TABLE OF CONTENTS  5.  6.  DISCUSSION  123  5.1  D e t e r m i n a n t s of s o l i d f o o d f e e d i n g practices  123  5.2  T h e c o n c e p t u a l m o d e l s of infant solid f o o d f e e d i n g  132  5.3  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 solid f o o d feeding  133  5.4  S t u d y limitations  137  5.5  Conclusions  141  F U T U R E DIRECTIONS  144  6.1.  Research  144  6.2.  Practice  145  REFERENCES  146  APPENDICES  154  V  TABLE OF CONTENTS LIST O F T A B L E S  T a b l e 1.  Description of the participant characteristics  44  T a b l e 2.  S u m m a r y of solid f o o d f e e d i n g strategies  88  Table 3.  T h e r e s o u r c e s u s e d b y s t u d y participants  92  T a b l e 4.  T h e r a n g e of solid f o o d s f e d to infants b e t w e e n 3 - 9 months of a g e  109  LIST O F F I G U R E S  F i g u r e 1.  C h a n g e s in b o d y iron c o n t e n t d u r i n g i n f a n c y  F i g u r e 2.  T h e effects of dietary c o m p o s i t i o n o n t h e relative bioavailability of iron  13  F i g u r e 3.  T h e C o n c e p t - Indicator M o d e l  27  F i g u r e 4.  The Causal - Consequence Model  28  F i g u r e 5.  T r a n s c r i p t o r g a n i z a t i o n a n d line c o d i n g ( L C ) p r o c e d u r e s  36  F i g u r e 6.  Indicator Index S u m m a r y S p r e a d s h e e t ( M S S ) for line c o d e o r g a n i z a t i o n  38  F i g u r e 7.  Memo Spreadsheet (MSa)  39  F i g u r e 8.  Concept/Category Summary Spreadsheet ( C C S S )  40  F i g u r e 9.  M e m o Spreadsheet (MSb)  41  Figure 10.  T h e 3 - d i m e n s i o n a l infant s o l i d f o o d f e e d i n g m o d e l  46  Figure 11.  T h e first t h e m e of the 3 - d i m e n s i o n a l infant s o l i d f o o d f e e d i n g m o d e l  47  Figure 12.  T h e s e c o n d t h e m e of the 3 - d i m e n s i o n a l infant s o l i d f o o d f e e d i n g m o d e l  57  Figure 13.  T h e third t h e m e of the 3 - d i m e n s i o n a l infant s o l i d f o o d f e e d i n g m o d e l  69  F i g u r e 14.  T h e fourth t h e m e of the 3 - d i m e n s i o n a l infant s o l i d f o o d f e e d i n g m o d e l  91  Figure 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 s o l i d f o o d f e e d i n g  103  F i g u r e 16.  T h e t y p e of milk f e d from birth t o 1 2 infants  114  F i g u r e 17.  T h e iron-fortified infant c e r e a l c o n s u m p t i o n patterns a m o n g infants  135  vi  8  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:  B a b y ' s First F o o d s B . C . Ministry of H e a l t h  154  A P P E N D I X B:  Ethics Approval  155  APPENDIX C:  Letter of Informed C o n s e n t  156  A P P E N D I X D:  Recruitment Checklist  157  A P P E N D I X E:  Infant F e e d i n g P r a c t i c e s Q u e s t i o n n a i r e  158  A P P E N D I X F:  Demographic Questionnaire  169  APPENDIX G:  Transition G r a p h s  176  A P P E N D I X H:  Feeding Techniques  183  A P P E N D I X I:  Feeding Strategies S u m m a r y  184  vii  ACKNOWLEDGEMENTS  ACKNOWLEDGEMENTS  I a p p r e c i a t e a n d s i n c e r e l y thank m y s u p e r v i s o r Dr. S h e i l a Innis for giving m e the opportunity to d o this u n i q u e r e s e a r c h project. H e r firm g u i d a n c e a n d support o v e r the past y e a r s h a s m a d e m e strive hard to d o m y best. M a n y t h a n k s to m y other c o m m i t t e e m e m b e r s Dr. G w e n C h a p m a n a n d Dr. Phyllis J o h n s o n for their excellent a s s i s t a n c e , g u i d a n c e a n d support in this challenging project. I a l s o w i s h to thank m y e x a m i n i n g c o m m i t t e e m e m b e r s H e l e n Y e u n g a n d Dr. R y n a L e v y - M i l n e for taking the time to review m y t h e s i s project a n d for their insight a n d expertise. I w o u l d like to t h a n k the m o t h e r s w h o p a r t i c i p a t e d in this s t u d y s o that I c o u l d l e a r n f r o m t h e m a n d h o p e f u l l y a d v a n c e u n d e r s t a n d i n g in t h e a r e a of infant s o l i d f o o d f e e d i n g a n d nutrition. I w o u l d like to e x t e n d a v e r y big t h a n k y o u to m y f r i e n d s for their unfailing s u p p o r t d u r i n g the m o r e difficult s t r e t c h e s a n d lots of fun a n d laughter d u r i n g t h e b e s t t i m e s . T h a n k y o u V i k k i , S y 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 v e r y s p e c i a l t h a n k y o u to m y w o n d e r f u l family; D o n , Ian, P e d r a , Hubert, a n d J o a n w h o h a d to m o v e f r o m their h o m e a n d f a m i l y to a c c o m m o d a t e m y s t u d i e s . T h e i r love a n d s m i l i n g f a c e s n e v e r c e a s e d to b e a s o u r c e of inspiration. M a n y t h a n k s to m y m o t h e r a n d h e r h u s b a n d D o n , w h o h a v e a l w a y s b e l i e v e d I c o u l d d o a n y t h i n g a n d to m y m o t h e r - i n - l a w S a n d y w h o h a s a l w a y s b e e n t h e r e o v e r t h e y e a r s w h e n I n e e d her. T o m y brother, w h o c o n t i n u e s to r e m i n d m e that h i g h e r e d u c a t i o n is highly o v e r r a t e d . L a s t l y , m y d e e p e s t gratitude a n d love to m y h u s b a n d , w h o h a s a l w a y s e n c o u r a g e d m e in m y e d u c a t i o n a n d intellectual a d v e n t u r e s .  viii  INTRODUCTION  Chapter I  T h e transition p e r i o d in infant f e e d i n g is d e f i n e d a s the time w h e n s e m i - s o l i d f o o d s a r e i n t r o d u c e d to infants, u s u a l l y at a b o u t 4 - 6 m o n t h s of a g e . W i t h a c c e p t a n c e in i n c r e a s i n g quantities, s o l i d f o o d s s l o w l y r e p l a c e the e x c l u s i v e milk diet a n d t h e diet p r o g r e s s e s to a ' m o d i f i e d ' t a b l e diet. T h e transition to a 'modified ' t a b l e diet is u s u a l l y c o m p l e t e b y 1 - 2 y e a r s of a g e . Infant f e e d i n g d u r i n g the e a r l y transition p e r i o d o c c u r r i n g f r o m 4 - 9 m o n t h s is c o m p l e x b e c a u s e of s e v e r a l k e y i s s u e s - i n t e n s e growth a n d t h u s high nutrient r e q u i r e m e n t s , the d e v e l o p m e n t a l s t a g e a n d thus p h y s i c a l r e a d i n e s s of the infant to a c c e p t f o o d s , a n d i n t e r a c t i o n s b e t w e e n the m o t h e r - t h e infant - a n d t h e e n v i r o n m e n t .  Infancy is a time of g r e a t  nutritional v u l n e r a b i l i t y b e c a u s e it is a p e r i o d of i n t e n s e growth a n d limited dietary variety. F o r i n s t a n c e , a n 8 - m o n t h - o l d infant r e q u i r e s m o r e t h a n t h r e e t i m e s a s m u c h iron p e r k i l o g r a m b o d y w e i g h t t h a n t h e a v e r a g e adult m a l e , a n d o v e r two-thirds of this iron is n e e d e d for growth ( D a l l m a n , 1 9 9 2 ) . G r a d u a l l y e x p a n d i n g t h e e x c l u s i v e milk diet (breast milk o r formula) to i n c l u d e s o l i d f o o d s e n a b l e s y o u n g infants to m e e t their c h a n g i n g nutritional n e e d s . W e a n i n g r e c o m m e n d a t i o n s a r e b a s e d o n t h r e e major f a c t o r s : nutritional n e e d , p h y s i o l o g i c a l maturation a n d d e v e l o p m e n t a l feeding issues (Hendricks a n d Badruddin, 1992). B a s e d on these 1  2  f a c t o r s , it is u s u a l l y r e c o m m e n d e d that t h e introduction of s o l i d f o o d s b e g i n s b e t w e e n 4 a n d 6 m o n t h s of a g e . T h e r e c o m m e n d a t i o n s a r e c o n s i d e r e d ' i d e a l ' b e c a u s e a s the milk diet b e c o m e s nutritionally insufficient ( W h i t h e a d , 1 9 8 5 a , b ; W H O , 1 9 8 5 ; U n d e r w o o d 1 9 8 5 ; F o r m a n , 1984) t h e addition of c o m p l e m e n t a r y f o o d s c o m p e n s a t e s for t h e nutrients that b e c o m e limited, thus providing a nutritionally a d e q u a t e diet. T h e m a j o r nutrients of c o n c e r n d u r i n g i n f a n c y in i n d u s t r i a l i z e d c o u n t r i e s i n c l u d e e n e r g y , iron, a n d v i t a m i n D. Iron d e f i c i e n c y , in particular, is a nutritional p r o b l e m a m o n g infants a n d y o u n g c h i l d r e n in C a n a d a . T h u s , p r e v e n t i o n of iron d e f i c i e n c y a n e m i a is a p r i m a r y f o c u s of nutrition expert groups ( C P S , 1991; C P S , 1998; Health a n d Welfare C a n a d a , 1986; T h e V a n c o u v e r Health Department, 1993) in C a n a d a .  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). 1  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 o n s e t of w e a n i n g is important b e c a u s e it is k n o w n that introducing s o l i d f o o d s 'too early or 'too late' c a n h a v e n e g a t i v e h e a l t h c o n s e q u e n c e s ( H e n d r i c k s a n d B a d r u d d i n , 1 9 9 2 ) . B y 4 - 6 5  m o n t h s of a g e the intestine a n d k i d n e y ( G r a n d , 1 9 7 6 ; S c a m m o n , 1 9 9 0 ; A k r e , 1 9 8 9 ) a r e better d e v e l o p e d to d i g e s t a n d a b s o r b c o m p l e x f o o d s , a n d t h e infant is r e a c h i n g important p h y s i c a l a n d n e u r o l o g i c a l m i l e s t o n e s (Ingram, 1 9 6 2 ; G e s e l l , 1 9 3 7 ; 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 s o l i d f o o d intake. A n infant f e d s o l i d s 'too e a r l y is at i n c r e a s e d risk f o r d i a r r h e a a n d a l l e r g i c d i s e a s e d u e to intestinal immaturity, w h i c h m a y c a u s e malnutrition.  In a d d i t i o n , e a r l y s o l i d f o o d introduction m a y l e a d to  d e c r e a s e d b r e a s t - m i l k p r o d u c t i o n b e c a u s e s o l i d f o o d s c a n d i s p l a c e milk intake. Infants f e d s o l i d s 'too late', o n the o t h e r h a n d , m a y d i s p l a y n e g a t i v e o u t c o m e s , including iron d e f i c i e n c y a n e m i a b e c a u s e h u m a n milk a l o n e c a n n o t m e e t iron n e e d s in the s e c o n d s i x m o n t h s of life. C o m p l e m e n t a r y s o l i d f o o d s that a r e a g e a n d nutrient a p p r o p r i a t e a r e , t h e r e f o r e , e s s e n t i a l for n o r m a l infant growth a n d d e v e l o p m e n t . Iron d e f i c i e n c y a n e m i a (IDA) is t h e m o s t c o m m o n nutritional d e f i c i e n c y in t h e w o r l d , affecting 3  a b o u t a q u a r t e r of all infants w o r l d w i d e (Lozoff, 1 9 9 6 ) . IDA is m o s t p r e v a l e n t b e t w e e n 6 a n d 2 4 m o n t h s of a g e b e c a u s e t h e iron s t o r e s a c c u m u l a t e d d u r i n g g e s t a t i o n a r e d e p l e t e d b y this t i m e a n d the r e q u i r e m e n t s to m e e t growth n e e d s a r e h i g h . F u r t h e r , t h e iron content a n d a b s o r p t i o n of different s o l i d f o o d s c o m m o n l y f e d to infants d u r i n g t h e transition p e r i o d v a r i e s . T h e c o m p o s i t i o n of v a r i o u s f o o d c o m b i n a t i o n s c a n a l s o positively or n e g a t i v e l y i n f l u e n c e iron bioavailability (e.g., e n h a n c e or inhibit iron a b s o r p t i o n ) . F o r s o m e infants, e a r l y f e e d i n g of non-fortified c o w s ' milk that is low in iron further i n c r e a s e s the risk of iron d e f i c i e n c y ( C P S , 1 9 9 1 ) . A l t h o u g h the national p r e v a l e n c e of iron d e f i c i e n c y in i n f a n c y in 4  C a n a d a is u n k n o w n s o m e p o p u l a t i o n s of infants a r e at high risk for p o o r iron s t a t u s . A recent s t u d y in V a n c o u v e r f o u n d a b o u t 1 5 % of b r e a s t - f e d 9 - m o n t h - o l d infants h a d iron d e f i c i e n c y a n e m i a , a n d a further 3 0 % w e r e iron deficient (Innis et a l . , 1 9 9 7 ) . A l t h o u g h t h e t y p e s of s o l i d f o o d s a n d h o w f o o d s a r e f e d to infants d u r i n g t h e transition p e r i o d c a n i n f l u e n c e d i e t a r y iron a d e q u a c y , d a t a a r e l a c k i n g o n t h e s o l i d f o o d f e e d i n g p r o c e s s . H e a l t h c a r e p r o f e s s i o n a l s , (Nutritionists, P u b l i c H e a l t h N u r s e s a n d D o c t o r s ) a n d m o t h e r s t h e m s e l v e s interpret a n d u s e the current infant f e e d i n g r e c o m m e n d a t i o n s .  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. 3  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. 4  2  INTRODUCTION However, data are lacking on how mothers feed iron containing solid foods, how mothers interpret the guidelines ( C P S , 1998) or whether or not mothers can follow the recommendations put forth by the guidelines, in a natural setting. T h e 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  T h e objectives of this s t u d y were: 1.  T o 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.  T o identify why mothers feed their infants solid foods in the way that they do, focusing on what influences cereal feeding practices and decisions.  3.  T o 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 C a n a d a and Health C a n a d a in Nutrition for Healthy Term Infants, 1998).  3  LITERATURE REVIEW  Chapter II  Infancy is a n important p e r i o d for p h y s i c a l a n d c o g n i t i v e d e v e l o p m e n t b e c a u s e at this t i m e nutritional p r o b l e m s c a n h a v e l o n g - t e r m effects both o n a t t a i n m e n t of p h y s i c a l growth a n d o n c o g n i t i v e f u n c t i o n s . T h e nutritional a d e q u a c y of the infant diet a n d f a c t o r s that i n f l u e n c e f o o d intake a r e critical for healt h a n d a c h i e v e m e n t . T h e diet p l a y s a n important role in infant iron s t a t u s b e c a u s e up to 3 0 % of the infant's b o d y r e q u i r e m e n t for iron m u s t b e d e r i v e d f r o m dietary s o u r c e s ( S m i t h , 1 9 7 4 ; F o m o n , 1 9 7 4 ) . Iron d e f i c i e n c y a n e m i a (IDA) is m o s t p r e v a l e n t b e t w e e n 6 - 2 4 m o n t h s of a g e . T h i s is further e m p h a s i z e d b y t h e fact that IDA is the m o s t c o m m o n s i n g l e nutrient d e f i c i e n c y in the w o r l d , affecting a p p r o x i m a t e l y 2 0 - 2 5 % of infants w o r l d w i d e (Lozoff 1 9 9 6 ) . R e s e a r c h is l a c k i n g o n t h e n a t i o n a l p r e v a l e n c e of iron d e f i c i e n c y a m o n g infants in C a n a d a . H o w e v e r , the s t u d i e s that h a v e b e e n c o m p l e t e d h a v e f o u n d that iron d e f i c i e n c y a n e m i a is a c o n s i d e r a b l e p r o b l e m , affecting 7 to o v e r 5 0 % of y o u n g infants ( C h a n Y i p a n d G r a y M a c D o n a l d , 1 9 8 7 ; G u p t a , et a l . , 1 9 9 9 ; Innis et a l . , 1 9 9 7 ; L e h m a n n e t ' a l . , 1 9 9 2 ; S a w c h u c k et a l . , 1 9 9 6 ; W a l e n et a l . , 1 9 9 7 ; W i l l o w s et a l . , 2 0 0 0 ) . D u r i n g t h e transition p e r i o d b e t w e e n 4 a n d 9 m o n t h s of a g e , milk is g r a d u a l l y r e p l a c e d with s e m i - s o l i d f o o d . T h e h i g h risk of iron d e f i c i e n c y in the s e c o n d s i x m o n t h s of life c o i n c i d e s with t h e transition p e r i o d . B o t h f a c t o r s - t h e h i g h d e m a n d for iron d u e to i n t e n s e growth a n d the low iron c o n t e n t a n d b i o a v a i l a b i l i t y of s o l i d f o o d s in t h e t r a n s i t i o n diet ( F a i r w e a t h e r - T a i t et a l . , 1 9 8 9 ; L y n c h , 1 9 9 7 ) i n c r e a s e the risk of iron d e f i c i e n c y . R e s e a r c h o n iron a n d s o l i d f o o d f e e d i n g h a s f o c u s e d primarily o n t h e a g e at w h i c h c o m p l e m e n t a r y (solid) f o o d s a r e i n t r o d u c e d to infants with little investigation o n u n d e r s t a n d i n g the m o r e c o m p l e x b e h a v i o r a l f a c t o r s that d e t e r m i n e s o l i d f o o d f e e d i n g o v e r t i m e , a n d t h u s potentially i n f l u e n c e infant iron nutrition. C l e a r l y , t h e w a y a m o t h e r f e e d s h e r infant iron c o n t a i n i n g s o l i d f o o d s h a s the potential to i m p a c t o n the infant's 5  a c c e p t a n c e of the f o o d s , a n d t h u s f o o d c o n s u m p t i o n patterns a n d dietary iron a d e q u a c y .  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.  5  4  LITERATURE REVIEW Information o n w h a t m o t i v a t e s m o t h e r s to f e e d their infants s o l i d f o o d s the w a y that t h e y d o is a l s o l a c k i n g . M u c h of the r e s e a r c h o n f a c t o r s i n f l u e n c i n g infant f e e d i n g c h o i c e s h a s f o c u s e d o n the d e t e r m i n a n t s of b r e a s t - f e e d i n g initiation a n d d u r a t i o n . A l t h o u g h this is interrelated with the introduction of s o l i d f o o d s , d e t e r m i n a n t s of b r e a s t - f e e d i n g c h o i c e s c a n n o t b e e x t r a p o l a t e d to u n d e r s t a n d i n g the s o l i d f o o d f e e d i n g p r o c e s s d u r i n g t h e transition p e r i o d . T h e e f f e c t i v e n e s s of infant f e e d i n g r e c o m m e n d a t i o n s d e s i g n e d to d e c r e a s e t h e risk of iron d e f i c i e n c y a n e m i a s h o u l d b e b a s e d , f u n d a m e n t a l l y , o n their e f f i c a c y , c o m p r e h e n s i v e n e s s a n d practical utility within the natural setting, a s w e l l a s t h e d i e t a r y iron c o n t e n t . T h i s r e v i e w p r o v i d e s a n o v e r v i e w of current r e s e a r c h in k e y a r e a s relevant to infant iron nutrition b e t w e e n t h e a g e of 4 a n d 9 m o n t h s w h e n m o s t h e a l t h y infants a r e u n d e r g o i n g t h e g r a d u a l transition f r o m a n e x c l u s i v e milk diet to a diet with milk a n d s e m i - s o l i d c o m p l e m e n t a r y f o o d s . T h e m a i n a r e a s this r e v i e w will f o c u s o n a r e iron s t a t u s , iron r e q u i r e m e n t s a n d nutritional b a l a n c e , diet c o m p o s i t i o n a n d f o o d iron a b s o r p t i o n , d i e t a r y c o n s u m p t i o n patterns, f o o d a c c e p t a n c e , b r e a s t - f e e d i n g a n d w e a n i n g p r a c t i c e s , a n d t h e infant f e e d i n g g u i d e l i n e s . B r e a s t f e e d i n g p r a c t i c e s a r e d i s c u s s e d b e c a u s e t h e y a r e c l o s e l y interrelated to the s o l i d f o o d diet a n d the risk of iron d e f i c i e n c y a n e m i a . C u r r e n t infant f e e d i n g g u i d e l i n e s a r e a l s o d e s c r i b e d to p r o v i d e a n u n d e r s t a n d i n g of t h e information that is a v a i l a b l e for health p r o f e s s i o n a l s a n d the p u b l i c a b o u t t h e transition to s o l i d f o o d s a n d p r e v e n t i o n of iron d e f i c i e n c y a n e m i a during infancy.  2.1.  Iron status - iron deficiency and anemia T h e i m p o r t a n c e of e n s u r i n g a d e q u a t e d i e t a r y iron i n t a k e s in infants a n d c h i l d r e n a s a  b a s i s tor p r e v e n t i o n of iron d e f i c i e n c y is a p u b l i c h e a l t h priority b e c a u s e i r o n - d e f i c i e n c y m a y b e a s s o c i a t e d with d e t r i m e n t a l effects o n t h e infant's b e h a v i o r a l , c o g n i t i v e a n d m o t o r d e v e l o p m e n t ( F o m o n a n d Z l o t k i n , 1 9 9 2 ) . T h e r e is a l s o e v i d e n c e that t h e treatment of iron d e f i c i e n c y a n e m i a m a y not c o m p l e t e l y c o r r e c t t h e a d v e r s e effects o n c o g n i t i v e d e v e l o p m e n t (Idjradinata et a l . , 1 9 9 3 ; L o z o f f et a l . , 1 9 9 1 ; L o z o f f et a l . , 1 9 9 6 ; Pollitt et a l . , 1 9 9 3 ; W a l t e r et a l . , 1 9 8 9 ) . In a d d i t i o n , a n i m a l s t u d i e s h a v e s h o w n that iron d e f i c i e n c y alters n e u r o l o g i c a l function a n d that t h e effects a r e  5  LITERATURE REVIEW related to a n insufficient s u p p l y of iron to different t i s s u e s for the s y n t h e s i s of v a r i o u s iron c o m p o u n d s , s u c h a s e n z y m e s ( B y n e s , 1 9 9 4 ; B e a r d et a l . , 1 9 9 3 ) . C u r r e n t d a t a o n t h e p r e v a l e n c e of iron d e f i c i e n c y a n d iron d e f i c i e n c y a n e m i a (IDA) in C a n a d i a n infants a r e limited. T h e p r e v a l e n c e of IDA a m o n g 6 - 1 4 m o n t h old infants living in a low s o c i o - e c o n o m i c e n v i r o n m e n t w a s reported to b e 2 5 - 2 7 % ( L e h m a n et a l . , 1 9 9 2 ; C h a n - Y i p a n d G r a y - D o n a l d , 1 9 8 7 ) . H i g h p r e v a l e n c e rates of IDA h a v e b e e n reported in First N a t i o n infants in C a n a d a (Moffatt, 1 9 9 5 ; S a w c h u c k et a l . , 1 9 9 6 ; W i l l o w s et a l . , 2 0 0 0 ; W a l e n et a l . , 1997). A recent s t u d y in B e l l a B e l l a , British C o l u m b i a f o u n d that 5 2 % of infants b e t w e e n the a g e s of 6 a n d 2 4 m o n t h s h a d a n e m i a ( H g b <100g/L) ( S a w c h u k et a l . , 1 9 9 6 ) . In northwestern O n t a r i o , 71 - 7 9 % of 6 to 12 m o n t h o l d infants h a d I D A ( H g b <110g/L) ( W a l e n et a l . , 1997). In northern Q u e b e c , 3 1 % of the infants h a d I D A ( H g b <110g/L) at 9 m o n t h s of a g e ( W i l l o w s et a l . , 2 0 0 0 ) . Infants from 8 to 18 m o n t h s of a g e in h i g h e r s o c i o - e c o n o m i c e n v i r o n m e n t s a n d u r b a n c e n t e r s a p p e a r to h a v e m u c h lower p r e v a l e n c e r a t e s , r a n g i n g f r o m 3.5 % to 7 % ( G r e e n e - F i n e s t o n e et a l . , 1 9 8 9 ; Innis et a l . , 1 9 9 7 ; Z l o t k i n et a l . , 1 9 9 6 ) . A l t h o u g h b r e a s t - f e e d i n g offers s o m e protection a g a i n s t the d e v e l o p m e n t of IDA ( C P S 1 9 9 8 ; M c M i l l i a n et a l . , 1 9 7 6 ; P i z z a r o et a l . , 1991), o t h e r s t u d i e s h a v e f o u n d that a l o n g e r duration of b r e a s t - f e e d i n g is a s s o c i a t e d with i n c r e a s e d risk ( C a l v o et a l , 1 9 9 2 ; C h a n - Y i p a n d G r a y - D o n a l d , 1 9 8 7 ; H e r t r a m p f et a l . , 1 9 8 6 ; Innis et a l . , 1 9 9 7 ; K i m et a l . , 1 9 9 6 ; S i i m e s et a l . , 1 9 8 4 ; W i l l o w s et a l . , 2 0 0 0 ) . F i v e r e c e n t s t u d i e s h a v e i n d i c a t e d m a j o r d i f f e r e n c e s in IDA b e t w e e n b r e a s t a n d f o r m u l a - f e d infants at a b o u t 9 m o n t h s of a g e . A l t h o u g h a recent s t u d y in V a n c o u v e r f o u n d the overall p r e v a l e n c e of IDA w a s 6 . 7 % , infants w h o w e r e b r e a s t - f e d for longer t h a n 8 m o n t h s h a d a p r e v a l e n c e of 1 5 . 5 % (Innis et a l . , 1 9 9 7 ) . W i l l o w s et a l . , (2000) f o u n d that IDA is highly p r e v a l e n t a m o n g First N a t i o n infants. T h e s e a u t h o r s r e p o r t e d s t r o n g a s s o c i a t i o n s b e t w e e n h e m o g l o b i n c o n c e n t r a t i o n a n d t h e t y p e of milk f e e d i n g at 9 m o n t h s of a g e . T h e y reported 4 3 % of b r e a s t - f e d a n d 1 6 % of f o r m u l a - f e d infants h a d IDA ( H g b < 1 1 0 g / L ) at 9 m o n t h s of a g e . S e v e r e a n e m i a ( H g b <100g/L) w a s f o u n d a m o n g 1.3% of the infants f e d f o r m u l a a n d 1 7 % of the infants w h o w e r e b r e a s t - f e d ( W i l l o w s et a l . , 2 0 0 0 ) . P i z a r r o et a l . , (1991) c o m b i n e d the results of three s t u d i e s involving a total of 8 5 4 9 m o n t h old infants c o m p l e t e d b e t w e e n 1 9 7 5 a n d 1 9 8 5 , in S a n t i a g o ,  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 ironfortified 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  L I T E R A T U R E 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 • Ivyo^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 m a i n t a i n a d e q u a t e iron s t o r e s . Iron d e f i c i e n c y p r o g r e s s e s in three s t a g e s or d e g r e e s of severity. T h e first s t a g e c o i n c i d e s with t h e d e p l e t i o n of iron s t o r e s . T h e s e c o n d s t a g e c o i n c i d e s with t h e i n a d e q u a c y of iron transport to the b o n e m a r r o w . T h e third a n d m o s t s e v e r e s t a g e , a n e m i a , c o i n c i d e s with a d e f e c t in h a e m o g l o b i n p r o d u c t i o n ( H e r c b e r g a n d G a l a n , 1 9 9 2 ) . T h e i m p a i r m e n t in t h e p r o d u c t i o n of e s s e n t i a l iron c o m p o u n d s is referred to a s iron d e f i c i e n c y . W h e n e s s e n t i a l iron c o m p o u n d s s u c h a s h a e m o g l o b i n , m i t o c h o n d r i a l iron p r o t e i n s ( c y t o c h r o m e s ) a n d iron sulfur proteins, that f u n c t i o n in o x i d a t i v e p r o d u c t i o n of c e l l u l a r e n e r g y in the f o r m of a d e n o s i n e t r i p h o s p h a t e a r e limited t h e n i m p a i r e d p h y s i o l o g i c a l f u n c t i o n is likely (Filer, 1 9 8 9 ) . L o w iron s t o r e s p e r s e i n d i c a t e that the infant is v u l n e r a b l e to iron d e f i c i e n c y ; the l o w e r the s t o r e s the m o r e v u l n e r a b l e t h e infant b e c o m e s ( D a l l m a n , 1 9 8 9 ) . T h e t e r m iron d e f i c i e n c y d o e s not p r o v i d e a s p e c i f i c d e s c r i p t i o n of the d e g r e e of iron d e p l e t i o n . Iron d e f i c i e n c y a n e m i a (IDA), o n t h e other h a n d , is a h e m a t o l o g i c state that r e s u l t s f r o m iron d e f i c i e n c y . In I D A , t h e b o d y iron s t o r e s (ferritin a n d h e m o s i d e r i n ) h a v e b e e n e x h a u s t e d a n d the infant is in t h e last s t a g e of iron d e f i c i e n c y in w h i c h t h e r e is insufficient iron for t h e s y n t h e s i s of h e m o g l o b i n . T h u s , I D A is t h e e n d result of a c u m u l a t i v e p r o c e s s of iron d e p l e t i o n that o c c u r s o v e r a p e r i o d of m o n t h s . T h e m e a s u r e m e n t of b o t h s e r u m ferritin a n d h a e m o g l o b i n reflect t h e iron s t a t u s of a l m o s t 9 0 % of b o d y iron ( B o t h w e l l , 1 9 7 9 ) . T h e 4 k e y f a c t o r s that i n f l u e n c e infant iron s t a t u s a n d risk of iron d e f i c i e n c y a r e the a b u n d a n c e of n e o n a t a l iron s t o r e s , b o d y iron l o s s e s ( b a s a l , p a t h o l o g i c , gastro-intestinal b l e e d i n g ) , t h e high d e m a n d s for iron d u r i n g rapid g r o w t h a n d t h e iron c o n t e n t of the diet. T h e iron c o n t e n t of t h e diet d e p e n d s o n t h e quantity c o n s u m e d , t h e f o r m of iron ( h e m e o r n o n - h e m e iron), a n d t h e o v e r a l l diet c o m p o s i t i o n ( B o t h w e l l et a l , 1 9 8 9 ; C h a r l t o n a n d B o t h w e l l , 1 9 8 3 ; C o o k a n d B o t h w e l l , 1 9 8 4 ; H a l l b e r g , 1 9 8 1 ; M c M i l l i a n et a l . , 1 9 7 6 ; S a a r i n e n et a l . , 1 9 7 7 ) . O f t h e s e 4 f a c t o r s , the infant's diet is t h e m o s t highly m o d i f i a b l e . T h e r e f o r e , the b a s i s of p r e v e n t i o n of IDA d u r i n g i n f a n c y is d i e t a r y m o d i f i c a t i o n . A c l e a r u n d e r s t a n d i n g of h o w m o t h e r s f e e d infants s o l i d f o o d s is r e q u i r e d in o r d e r to u n d e r s t a n d h o w to m o d i f y t h e infant's diet to p r e v e n t iron d e f i c i e n c y .  9  LITERATURE REVIEW  2.2.2. Diet composition and food iron absorption T h e diet c a n i n f l u e n c e infant iron s t a t u s a n d the risk of IDA in 3 w a y s : the iron content (quantity), the f o r m of iron i n g e s t e d ( h e m e o r n o n - h e m e iron) a n d the c o m p o s i t i o n of the diet ( B o t h w e l l et a l . , 1 9 8 9 ; C h a r l t o n a n d B o t h w e l l , 1 9 8 3 ; C o o k a n d B o t h w e l l , 1 9 8 4 ; H a l l b e r g , 1 9 8 1 ; M c M i l l i a n et a l . , 1 9 7 6 ; S a a r i n e n et a l . , 1 9 7 7 ) . T h e m a j o r s o u r c e s of dietary iron in later i n f a n c y a r e b r e a s t milk, iron-fortified infant f o r m u l a s , iron-fortified infant c e r e a l s a n d m e a t s . H u m a n milk p r o v i d e s a b o u t 0 . 2 6 m g of iron p e r d a y , b a s e d o n a t y p i c a l daily c o n s u m p t i o n of 7 5 0 m L m i l k / d a y with a n iron c o n t e n t of 0 . 3 5 m g / L milk ( S a a r i n e n , S i i m e s et a l . , 1 9 7 7 ; H e a l t h a n d W e l f a r e C a n a d a , 1 9 9 0 ) . H o w e v e r , t h e r a n g e of iron in h u m a n milk v a r i e s b e t w e e n 0.2 to 0 . 8 m g / L ( L R S O , 1 9 9 8 ) . Further, t h e a b s o r p t i o n of iron f r o m h u m a n milk r a n g e s f r o m 12 to 5 0 % ( A b r a m s et a l . , 1 9 9 7 ; D a v i d s s o n et a l . , 1 9 9 4 b ; H a l l b e r g et a l . , 1 9 9 2 : M c M i l l a n et a l . , 1 9 7 7 ; S a a r i n e n et a l . , 1 9 7 7 : S c h u l z - L e l l et a l . , 1 9 8 7 ) . A t a n a v e r a g e iron content of 0.26 m g , a n d a s s u m i n g 5 0 % a b s o r p t i o n , t h e infant w o u l d a b s o r b a b o u t 0 . 1 2 m g / d a y of iron f r o m h u m a n milk. A l t e r n a t e l y , a s s u m i n g t h e m a x i m u m iron in h u m a n milk of 0.8 m g / L , a m a x i m u m a b s o r p t i o n of 5 0 % , a n d a high c o n s u m p t i o n l e v e l of 1 0 0 0 m L of milk p e r d a y , the infant w o u l d a b s o r b a t h e o r e t i c a l m a x i m u m of a b o u t 0 . 4 0 m g i r o n / d a y . H o w e v e r , with m a x i m u m a b s o r p t i o n a n d the m i n i m u m iron c o n t e n t in h u m a n milk (0.2 m g / L ) , the infant w o u l d a b s o r b o n l y a b o u t 0 . 1 0 m g iron p e r d a y . S i m i l a r l y , s i n c e iron a b s o r p t i o n d e c r e a s e s with t h e i n c r e a s i n g a m o u n t of iron p r o v i d e d f r o m the f o o d , a s s u m i n g a m o r e likely a b s o r p t i o n rate of 1 2 % with 0.8 m g / L iron, the infant w o u l d a l s o o n l y a b s o r b a b o u t 0 . 1 0 m g i r o n / d a y f r o m 1 0 0 0 m L of milk. T h i s 4-fold d i f f e r e n c e in p o t e n t i a l iron a b s o r p t i o n a m o n g the b r e a s t - f e d infants c r e a t e s c h a l l e n g e s to e s t i m a t i n g the a m o u n t of iron o b t a i n e d f r o m b r e a s t milk a l o n e , a n d t h u s f r o m c o m p l e m e n t a r y f o o d s . Infant c e r e a l c o n t a i n s a p p r o x i m a t e l y 3 m g of iron (2.7 - 3.5 mg) p e r 3 t a b l e s p o o n s of d r y infant c e r e a l ( H e a l t h a n d W e l f a r e C a n a d a , 1 9 8 6 ) . R i o s et a l . , (1975) f o u n d that the m e a n a b s o r p t i o n of electrolytic iron f r o m m i x e d c e r e a l w a s 4 . 0 % .  W i t h a n a b s o r p t i o n of 4 . 0 % , 4  t a b l e s p o o n s of dry infant c e r e a l w o u l d p r o v i d e a b o u t 0 . 1 3 m g of iron. T h e c o m b i n e d total iron c o n t e n t of h u m a n milk ( 0 . 3 m g / L ) p l u s 8 t a b l e s p o o n s of infant c e r e a l p e r d a y c o u l d t h e o r e t i c a l l y p r o v i d e a b o u t 0.6 m g , c l o s e to the e s t i m a t e d r e q u i r e m e n t of 0.7 m g / d a y . C l e a r l y , the s o l i d f o o d  10  L I T E R A T U R E REVIEW f e e d i n g p r a c t i c e s of the m o t h e r will affect the s o l i d f o o d intake, a n d t h u s iron s t a t u s of the infant. T h u s , a n u n d e r s t a n d i n g of f a c t o r s that i n f l u e n c e infant s o l i d f o o d c o n s u m p t i o n patterns is important to identifying p r a c t i c e s that p r o m o t e or d e c r e a s e the c o n s u m p t i o n of iron-fortified first foods. In a d d i t i o n to the quantity of iron in f o o d , both the f o r m of the iron a n d t h e c o m p o s i t i o n of .the diet a l s o i n f l u e n c e iron bioavailability.  In fact, t h e f o r m of the iron in f o o d a n d t h e effect of f o o d  c o m b i n a t i o n s o n iron bioavailability c a n h a v e a g r e a t e r i m p a c t o n iron nutrition t h a n the total a m o u n t of iron in t h e diet ( C h a r l t o n et a l . , 1 9 8 3 ; C o o k e t a l . , 1 9 8 4 ; H a l l b e r g , 1 9 8 1 ; M c M i l l a n et a l . , 1 9 7 6 ; O s k i et a l . , 1 9 8 0 ; S a a r i n e n et a l . , 1 9 7 7 ) . T h e interplay b e t w e e n p r o m o t e r s a n d inhibitors of iron a b s o r p t i o n a r e k e y to the bioavailability of n o n - h e m e iron. A brief r e v i e w of the t y p e s of iron in the diet is n e e d e d in o r d e r to u n d e r s t a n d iron a b s o r p t i o n a n d illustrate t h e potential d i f f e r e n c e s in iron a b s o r p t i o n in relation to t h e t y p e of c o m p l e x m e a l s a n infant might c o n s u m e . T h e two f o r m s of iron in t h e diet - h e m e a n d n o n - h e m e iron, differ with r e s p e c t to bioavailability ( H a l l b e r g , 1 9 8 9 ; R o s s a n d e r - H u l t h e n a n d H a l l b e r g , 1 9 9 6 ) . H e m e iron w h i c h is p r e s e n t in a n i m a l t i s s u e s is a b s o r b e d at a high rate ( - 2 5 % ) a n d this a b s o r p t i o n is g e n e r a l l y i n d e p e n d e n t of iron s t a t u s a n d d i e t a r y inhibitors a n d p r o m o t e r s of iron a b s o r p t i o n ( M o n s e n et a l . , 1978). N o n - h e m e iron, w h i c h is f o u n d in n o n m e a t s o u r c e s i n c l u d i n g d a i r y f o o d s , h a s a w i d e r a n g e of a b s o r p t i o n of 5 - 2 0 % , a n d t h e a b s o r p t i o n of n o n - h e m e iron d e p e n d s o n the i n d i v i d u a l ' s iron s t a t u s a n d t h e c o m p o s i t i o n of the diet (factors e n h a n c i n g or inhibiting a b s o r p t i o n ) . It h a s b e e n g e n e r a l l y a g r e e d that t h e m a j o r f a c t o r s e n h a n c i n g n o n - h e m e iron a b s o r p t i o n i n c l u d e a s c o r b i c a c i d , m e a t , poultry a n d fish a n d o r g a n i c a c i d s (citric, lactic, m a l i c , a n d tartaric a c i d s ) ( H a l l b e r g , 1 9 8 9 ; L y n c h , 1 9 9 7 ) . E n g e l m a n n et a l . , (1998) i n v e s t i g a t e d the i n f l u e n c e of m e a t o n n o n - h e m e iron a b s o r p t i o n in a c r o s s - o v e r d e s i g n with 8, 4 3 - 4 9 w e e k o l d infants a n d f o u n d that n o n - h e m e iron a b s o r p t i o n w a s significantly i n c r e a s e d ( 1 5 % f r o m 9.9%) from the v e g e t a b l e mixture w h e n m e a t w a s a d d e d . T h e m a j o r f a c t o r s that inhibit n o n - h e m e iron a b s o r p t i o n i n c l u d e p h y t a t e s , w h i c h a r e f o u n d in all c e r e a l s a n d s o y p r o d u c t s , p o l y p h e n o l s in t e a , c o f f e e , v e g e t a b l e s a n d fruits, s o m e proteins ( e g g a l b u m i n a n d l e g u m e protein) a n d s o m e i n o r g a n i c e l e m e n t s ( c a l c i u m ) ( F a i r w e a t h e r - T a i t , 1 9 8 9 ; F A C V W H O , 1 9 8 8 ) . F u r t h e r , d a t a a r e a v a i l a b l e to s u g g e s t that  11  LITERATURE REVIEW s o l i d f o o d f e e d i n g patterns m a y interfere with t h e a b s o r p t i o n of iron f r o m b r e a s t milk, a n d h e n c e i n f l u e n c e the iron s t a t u s of t h e infant ( O s k i a n d L a n d a w , 1 9 8 0 ) . C o n t i n u e d r e s e a r c h o n ' f o o d c o m b i n a t i o n s ' that p r o m o t e n o n - h e m e iron a b s o r p t i o n m a y better e l u c i d a t e the link b e t w e e n f o o d m i x t u r e s that a r e f e d to infants a n d t h e a b s o r p t i o n of dietary iron ( F a i r w e a t h e r - T a i t et a l , . 1 9 9 5 ; F o x et a l . , 1 9 9 8 ; F u c h s et a l . , 1 9 9 3 ) . T h e g e n e r a l effects of diet c o m p o s i t i o n o n t h e relative bioavailabiltiy of iron h a v e b e e n d e s c r i b e d ( F A O / W H O , 1 9 8 8 ) . D i e t s h a v e b e e n d i v i d e d into low, i n t e r m e d i a t e , a n d high iron bioavailability that c o r r e s p o n d e d to a b s o r p t i o n rates of a b o u t 5 % , 1 0 % , a n d 1 5 % r e s p e c t i v e l y (in the p r e s e n c e of low iron s t o r e s ) . M o n s e n et a l . , (1978) state that a diet with low iron bioavailability h a s a h i g h inhibitor c o n t e n t with f e w p r o m o t e r s in t h e f o r m of m e a t , f i s h or a s c o r b i c a c i d . U s i n g t h e m o d e l d e s c r i b e d b y M o n s e n et a l . , (1978), t h e p e r c e n t a g e of iron a b s o r b e d f r o m a t y p i c a l s i n g l e m e a l f r o m t h e C a n a d i a n diet is a s s u m e d to b e 1 2 . 5 % (Health a n d W e l f a r e C a n a d a , 1 9 9 0 ) . T h e r e c o m m e n d e d dietary iron intake for 5 - 12 m o n t h o l d infants is 7.0 m g / d a y a n d is d e r i v e d f r o m the total iron r e q u i r e m e n t of 0.7 m g / d a y with a n a s s u m e d factor of 1 0 % for a b s o r p t i o n ( H e a l t h a n d W e l f a r e C a n a d a , 1 9 9 0 ) . H o w e v e r , t h e s o l i d f o o d transition diet of y o u n g infants ( 4 - 9 m o n t h s ) c o n t a i n s p r e d o m i n a n t l y iron of low bioavailability (5%) ( F A O / W H O , 1 9 8 8 ; Y e u n g et a l , 1 9 8 1 ) . T h e f o l l o w i n g figure e m p h a s i z e s t h e effects of diet c o m p o s i t i o n o n the relative bioavailability of iron f r o m f o o d a n d highlights the 'vulnerability' of infants to low iron s t a t u s d u e to a d e q u a t e iron i n t a k e a n d a b s o r p t i o n f r o m typical w e a n i n g f o o d s .  12  LITERATURE REVIEW  High Bioavailability (>15%)  Intermediate Bioavailability (10%)  G e n e r o u s quantities of; -Meat and/or -Ascorbic acid  Low Bioavailability (5%) -Whole wheat flour, beans, rice, corn P L U S Very small quantities of; -Meat and/or -Ascorbic acid  -Whole wheat flour, potatoes, beans, rice, corn PLUS some  PLUS -White flour products (bread/pasta), Fruits and Vegetables  -Meat and/or -Ascorbic acid  Figure. 2. T h e 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 F A C 7 W H O , 1988).  A n 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 R E V I E W (1981) f o u n d that s o l i d f o o d h a d b e e n i n t r o d u c e d to 7 8 % a n d 7 0 % of infants, r e s p e c t i v e l y , b y 3 m o n t h s of a g e . In t h e e a r l y 1 9 8 0 ' s , T a n a k a et a l . , ( 1 9 8 7 ) 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 r e n d to later introduction, with o n l y 4 2 % a n d 3 3 . 8 % , r e s p e c t i v e l y , of infants i n t r o d u c e d to s o l i d f o o d s b y 3 m o n t h s of a g e . In a recent s t u d y in V a n c o u v e r , this trend t o w a r d later introduction of s o l i d f o o d s w a s e v e n m o r e a p p a r e n t . W i l l i a m s et a l . , (1996) f o u n d that o n l y 7 . 8 % of infants in V a n c o u v e r h a d b e e n g i v e n iron-fortified infant c e r e a l s b e f o r e 4 m o n t h s of a g e . T h i s trend to later introduction of s o l i d f o o d s is m o r e c l o s e l y a l i g n e d with t h e current C a n a d i a n P e d i a t r i c S o c i e t y ( C P S ) Nutrition C o m m i t t e e r e c o m m e n d a t i o n s a n d c o i n c i d e s with the s o c i e t a l shift t o w a r d s a n i n c r e a s e d initiation a n d d u r a t i o n of b r e a s t - f e e d i n g . H o w e v e r , W i l l i a m s et a l . , (1996) a l s o f o u n d that iron-fortified c e r e a l h a d not b e e n g i v e n to 6 . 7 % of the infants b y 7 - 9 m o n t h s of a g e , a n d m e a t s , c h i c k e n o r f i s h h a d not b e e n g i v e n t o 3 3 % , 2 4 % a n d 6 2 % , r e s p e c t i v e l y , of the infants b y 9 m o n t h s of a g e . P o s s i b l y , the later introduction of h e m e iron c o n t a i n i n g f o o d s 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 c o u l d i m p a c t o n iron s t a t u s at 9 m o n t h s of a g e . T w o s t u d i e s h a v e r e p o r t e d that f e e d i n g infants iron fortified c e r e a l s for l e s s t h a n 3 m o n t h s ( G r e e n e - F i n e s t o n e et a l . , 1989) o r l e s s t h a n 6 m o n t h s ( L e h a m n n et a l . , 1992) w a s a s s o c i a t e d with a n i n c r e a s e d risk of IDA. H o w e v e r , t h e r e a p p e a r s to b e n o p u b l i s h e d d a t a o n w h e t h e r the m o t h e r ' s k n o w l e d g e o r p e r c e p t i o n s a b o u t the i m p o r t a n c e of f e e d i n g iron c o n t a i n i n g solid foods influences s u b s e q u e n t feeding practices. T h e last Infant Nutrition S u r v e y ( 1 9 7 7 - 7 8 ) in C a n a d a f o u n d that a s e g m e n t of the infant p o p u l a t i o n c o u l d h a v e d i e t s d e f i c i e n t in iron ( Y e u n g et a l . , 1 9 8 3 ) . T o a s s e s s the a d e q u a c y of dietary iron i n t a k e s , the m e a n iron intake w a s c o m p a r e d with the c u r r e n t r e c o m m e n d e d intake of 7 m g / d a y for infants 5 to 12 m o n t h s of a g e . T h e probability of iron d e f i c i e n c y w a s t h e n a p p r o x i m a t e d ( b i o c h e m i c a l d a t a w e r e not u s e d ) . T h e p r o p o r t i o n s of 6, 8 , 1 0 , a n d 12 m o n t h o l d infants with a n i n a d e q u a t e i n t a k e of iron w e r e 3 5 % , 3 3 % , 3 7 % a n d 5 3 % , r e s p e c t i v e l y , a n d the p r o b a b l e p r o p o r t i o n s of infants with iron d e f i c i e n c y a n e m i a w e r e 2 1 % , 1 8 % , 2 0 % a n d 3 3 % , r e s p e c t i v e l y ( Y e u n g , 1 9 8 3 ) . H o w e v e r , s i n c e the iron p r o v i d e d b y b r e a s t milk w a s not i n c l u d e d in t h e a n a l y s i s of t h e m e a n d i e t a r y i r o n i n t a k e , t h e v a l u e s a r e m o s t likely h i g h e r t h a n w o u l d b e e x p e c t e d . F r o m 3 - 1 0 m o n t h s of a g e , 7 0 % to 9 3 % of the infants in this s t u d y w e r e r e c e i v i n g  14  LITERATURE REVIEW infant c e r e a l s a n d t h e a m o u n t t h e y c o n s u m e d a v e r a g e d 18 - 2 0 g r a m s p e r d a y . T h i s a m o u n t of c e r e a l w o u l d contribute a b o u t 7 0 % of t h e total iron r e q u i r e m e n t , a s s u m i n g 1 0 % a b s o r p t i o n ( 7 0 % of 7 m g is 4 . 9 m g of dietary iron). H o w e v e r , if the n o n - h e m e c e r e a l iron w a s a b s o r b e d at o n l y 5 % rather t h a n 1 0 % o n l y a b o u t 3 0 % of the iron r e q u i r e m e n t ( 0.7 m g p e r day) w o u l d b e met. Y e u n g (1983) s u g g e s t e d that t h e m a i n c a u s e of the h i g h p r e v a l e n c e of iron d e f i c i e n c y a s t h e infant g r e w o l d e r w a s t h e r e p l a c e m e n t of iron-fortified infant c e r e a l s with adult c e r e a l s a n d t a b l e f o o d s , w h i c h c o n t a i n o n l y 5 0 - 3 5 % of t h e iron f o u n d in infant c e r e a l s . H o w e v e r , t h e l a c k of d a t a o n t h e a m o u n t of iron a b s o r b e d f r o m iron-fortified infant c e r e a l s , p o s s i b l e a d v e r s e effects of c o w s ' milk in t h e infant diet, a n d t h e a m o u n t s of c e r e a l c o n s u m e d o v e r time limit the interpretation of p o p u l a t i o n d a t a o n dietary iron i n t a k e . M o r e recently, s e v e r a l s t u d i e s h a v e s u g g e s t e d that t h e r e a r e d i f f e r e n c e s in the s o l i d f o o d c o n s u m p t i o n p a t t e r n s b e t w e e n b r e a s t - f e d infants a n d infants f e d f o r m u l a . W a l t e r et a l . , ( 1 9 9 3 ) reported that f o r m u l a - f e d infants c o n s u m e d 2 7 g m s , 3 0 g m s , a n d 3 1 g m s / d a y of infant c e r e a l c o m p a r e d with 1 0 g m s , 2 0 g m s , a n d 2 3 g m s / d a y b y b r e a s t - f e d infants at 5, 6, a n d 7 m o n t h s of a g e , r e s p e c t i v e l y . F u r t h e r , t h e c e r e a l intake w a s a l s o significantly different b e t w e e n the 2 g r o u p s at 8 m o n t h s of a g e . It s e e m s p o s s i b l e that t h e c u m u l a t i v e i m p a c t of l o w e r infant c e r e a l c o n s u m p t i o n c o u l d i n c r e a s e t h e risk of iron d e f i c i e n c y a m o n g b r e a s t - f e d infants. L o n g i t u d i n a l s t u d i e s to s h o w this, h o w e v e r , a r e l a c k i n g . H e i n i g et a l . , (1993) a l s o f o u n d d i f f e r e n c e s in s o l i d f o o d f e e d i n g b e t w e e n b r e a s t - f e d a n d f o r m u l a - f e d infants, but the d i f f e r e n c e s w e r e in introduction of s o l i d f o o d s 'other t h a n c e r e a l s , that a r e important to iron nutrition. A t 9 m o n t h s of a g e , m e a t s , 1  f i s h , a n d poultry h a d b e e n i n t r o d u c e d to 8 7 % of the f o r m u l a - f e d infants but to o n l y 5 2 % of b r e a s t f e d infants. F u r t h e r m o r e , 6 3 % of t h e b r e a s t - f e d infants c o m p a r e d with 3 1 % of f o r m u l a - f e d infants h a d b e e n g i v e n d a i r y p r o d u c t s at 9 m o n t h s . A s w o u l d b e e x p e c t e d , t h e s e d i f f e r e n c e s d i s a p p e a r e d b y 12 m o n t h s ( H e i n i g et a l . , 1 9 9 3 ) . In s u m m a r y , t h e a v a i l a b l e literature s u g g e s t s that infants m a y b e f e d s o l i d f o o d differently d e p e n d i n g o n w h e t h e r t h e infant is b r e a s t - f e d or bottle-fed with infant f o r m u l a . B r e a s t - f e d infants a p p e a r to c o n s u m e l e s s iron-fortified infant c e r e a l , to b e i n t r o d u c e d to h e m e iron s o u r c e s later, a n d to b e i n t r o d u c e d to d a i r y p r o d u c t s ( w h i c h inhibit iron a b s o r p t i o n ) s o o n e r t h a n f o r m u l a - f e d  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. T h e 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, a s 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. L e s s 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. T h e 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 milkcereal combination over the water-cereal combination. Observation of videotaped infant cues  16  LITERATURE REVIEW a l s o s h o w e d m i l k - c e r e a l mixture p r e f e r e n c e s . T h i s s t u d y s u g g e s t s that the c e r e a l p r e p a r a t i o n m e t h o d (i.e., altering flavors) i n f l u e n c e d t h e infant's a c c e p t a n c e of the c e r e a l . S t e p h e n s o n et a l . , (1994) c o m p a r e d the effects of f e e d i n g a low-density p o r r i d g e (2.15 k J / g ) , a thick h i g h - d e n s i t y p o r r i d g e (4.09 k J / g ) , a n d a n a m y l a s e r e d u c e d v i s c o s i t y p o r r i d g e in 15 n o n b r e a s t - f e d infants of 7 - 15 m o n t h s of a g e . A l t h o u g h the m e a n daily c o n s u m p t i o n of the t h i c k e n e d p o r r i d g e w a s significantly lower, the d a i l y e n e r g y intake w a s significantly higher. Further, t h e m e a l d u r a t i o n w a s a l m o s t t w i c e a s l o n g with t h e thick porridge m e a l c o m p a r e d with the l o w - d e n s i t y p o r r i d g e . S i n c e the ' t h i n n e d ' v i s c o s i t y p o r r i d g e did not i n c r e a s e e n e r g y intake, t h e s e a u t h o r s s u g g e s t s i m p l y m a k i n g w e a n i n g f o o d s t h i c k e r a n d a d d i n g s u c h f o o d s a s oil, o r p e a n u t butter c a n b e u s e d to i n c r e a s e the e n e r g y d e n s i t y of f o o d e a t e n . T h i s s t u d y s u g g e s t s that the texture, in a d d i t i o n to t h e flavor, of the f o o d c a n i n f l u e n c e c e r e a l c o n s u m p t i o n . C o h e n et a l . , (1995) r e p o r t e d that d e l a y i n g t h e introduction of c o m p l e m e n t a r y f o o d s until 6 m o n t h s w h e n c o m p a r e d with introduction at 4 m o n t h s did not affect appetite or f o o d a c c e p t a n c e a m o n g e x c l u s i v e l y b r e a s t - f e d infants w h e n s t u d i e d later at 9 a n d 12 m o n t h s of a g e . T h e r e w e r e no d i f f e r e n c e s f o u n d in t h e b r e a s t - f e e d i n g f r e q u e n c y , the a m o u n t or n u m b e r of f o o d s c o n s u m e d at t h e m i d d a y m e a l , the a m o u n t of f o o d offered that w a s c o n s u m e d , the u s u a l d a i l y n u m b e r of m e a l s a n d s n a c k s , t h e n u m b e r of f o o d g r o u p s c o n s u m e d , or t h e overall f o o d a c c e p t a n c e s c o r e at 9 a n d 12 m o n t h s of a g e . H o w e v e r , the interpretation of this d a t a is limited s i n c e the infants' f o o d r e s p o n s e s d u r i n g t h e transition p e r i o d f r o m 4 to 9 m o n t h s w a s not d e s c r i b e d . T h e v e r b a l o r n o n - v e r b a l c u e s w h i c h infants d i s p l a y w h e n offered f o o d a n d d u r i n g f e e d i n g a r e r e s p o n s e s to a c o m p l e x s e t of f a c t o r s (for e x a m p l e , d e v e l o p m e n t a l r e a d i n e s s , f o o d p r e f e r e n c e s , satiety o r t i r e d n e s s ) . F u r t h e r , f e e d i n g d y n a m i c s m a y p l a y a critical role in f o o d a c c e p t a n c e a n d thus c o n s u m p t i o n p a t t e r n s . S a t t e r (1990) h a s n o t e d that effective f e e d i n g i n c l u d e s a l l o w i n g t h e infant to d e t e r m i n e f o o d t i m i n g , a m o u n t , p r e f e r e n c e , p a c i n g , e a t i n g capability, a n d p r o v i d i n g the opportunity to e x p l o r e t h e f o o d . S h e s t a t e s that s u p p o r t i v e p o s i t i v e f e e d i n g d y n a m i c s a r e important for p r e v e n t i o n of f e e d i n g p r o b l e m s . S a t t e r (1990) h a s c h a r a c t e r i z e d infant d e v e l o p m e n t a l p r i n c i p l e s that g u i d e f e e d i n g o v e r the first 3 6 m o n t h s of life.  O f note, t h e  ' s e p a r a t i o n i n d i v i d u a t i o n ' s t a g e that b e g i n s at a b o u t 6 m o n t h s of a g e is a d e v e l o p m e n t a l s t a g e  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. T h e s e 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 s e e m 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 ( C P S , 1998). Although the breast-feeding initiation and duration rates in  C a n a d a have both increased in the last 25 years they still fall short of the current recommendations to exclusively breast-feed for at least 4 ( C P S , 1991; C P S , 1998; Vancouver Health Dept. 1993), or 6 months (O'Brian et al., 1998; W H O / U N I C E F , 1989). Data on breastfeeding trends in C a n a d a 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 C a n a d a 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. T h e 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 C a n a d a (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 p o s t p a r t u m . T h e definition ' e x c l u s i v e l y b r e a s t - f e d in the latter s t u d y w a s b r e a s t - f e e d i n g with n o 1  bottle-feeding of f o r m u l a or c o w s ' milk. B r e a s t - f e e d i n g d u r a t i o n rates h a v e a l s o i n c r e a s e d f r o m 1 4 % to 4 4 % b r e a s t - f e e d i n g to 4 m o n t h s a n d f r o m 7 % to 3 1 % b r e a s t - f e e d i n g to 6 m o n t h s , f r o m 1 9 6 3 to 1 9 8 2 , r e s p e c t i v e l y ( M c N a l l y et a l . , 1 9 8 5 ) . A l t h o u g h b r e a s t - f e e d i n g initiation rates in C a n a d a h a v e i m p r o v e d d r a m a t i c a l l y d u r i n g the last 2 0 y e a r s , the n u m b e r of m o t h e r s b r e a s t f e e d i n g to 6 m o n t h s of a g e h a s s t a y e d at a b o u t o n l y 3 0 % s i n c e t h e e a r l y 1 9 8 0 ' s , ( M c N a l l y et a l . , 1 9 8 5 ; T a n a k a et a l . , 1 9 8 7 ; W i l l i a m s et a l . , 1 9 9 6 ) . W h e t h e r s o l i d f o o d f e e d i n g p r a c t i c e s i m p a c t b r e a s t - f e e d i n g p r a c t i c e s , in particular, b r e a s t - f e e d i n g d u r a t i o n is u n c l e a r . T h e proportion of infants f e d s o l i d f o o d s b e f o r e 4 m o n t h s of a g e h a s d e c r e a s e d s u b s t a n t i a l l y o v e r the p a s t 2 0 y e a r s . In 1 9 7 7 - 7 8 , the m e d i a n a g e at w h i c h m o t h e r s i n t r o d u c e d s o l i d f o o d s w a s l e s s t h a n 2 m o n t h s , with 6 5 % introducing s o l i d f o o d s b y 1 m o n t h of a g e ( T a n a k a et a l . , 1 9 8 7 ) . In c o n t r a s t , b y 1 9 8 4 - 8 5 , t h e m e d i a n a g e for s o l i d f o o d introduction w a s 4 m o n t h s . B y 6 m o n t h s of a g e , a b o u t 9 0 % of infants in s t u d i e s b e t w e e n 1 9 7 7 a n d 1 9 9 6 w e r e r e c e i v i n g infant c e r e a l ( T a n a k a et a l . , 1 9 8 7 ; W i l l i a m s et a l . , 1 9 9 6 ; Y e u n g , 1 9 8 1 ) . G r e e n e - F i n e s t o n e et a l . , (1989) reported that 3 t i m e s m o r e infants of low s o c i o e c o n o m i c s t a t u s ( S E S ) r e c e i v e d s o l i d s prior to 3 m o n t h s of a g e w h e n c o m p a r e d to infants of a h i g h S E S . T h e s e a u t h o r s a l s o s h o w e d that m o t h e r s w h o did not b r e a s t - f e e d i n t r o d u c e d s o l i d s a b o u t 1 m o n t h earlier t h a n m o t h e r s w h o b r e a s t - f e d a n d bottle-fed, o r w h o o n l y b r e a s t - f e d . T h i s s u g g e s t s a link b e t w e e n lower e d u c a t i o n l e v e l , l o w e r i n c o m e a n d s o c i o - e c o n o m i c s t a t u s , bottle-feeding a n d earlier introduction of s o l i d f o o d s ( B e a u d r y et a l . , 1 9 8 9 ; B e r g e r m a n et a l . , 1 9 7 9 ; G r e e n e - F i n e s t o n e et a l . , 1 9 8 9 ; S t e w a r t et al., 1987). N u m e r o u s s t u d i e s h a v e e x a m i n e d f a c t o r s that a r e a s s o c i a t e d with a m o t h e r ' s d e c i s i o n to b r e a s t - f e e d a n d to w e a n . T h e s e s t u d i e s h a v e identified d e m o g r a p h i c f a c t o r s s u c h a s m a t e r n a l a g e , e d u c a t i o n , i n c o m e , marital s t a t u s , ethnicity a n d p s y c h o s o c i a l v a r i a b l e s s u c h a s attitudes, s t r e s s a n d s u p p o r t a s important d e t e r m i n a n t s of infant f e e d i n g p r a c t i c e s . S u c c e s s f u l b r e a s t f e e d i n g i n v o l v e s a c o m p l e x interaction of f a c t o r s that a r e r e c i p r o c a l l y d e t e r m i n e d by internal p e r s o n a l a n d s o c i o - e n v i r o n m e n t a l f a c t o r s . T h e internal p e r s o n a l f a c t o r s that m a y d e t e r m i n e b r e a s t - f e e d i n g duration i n c l u d e ; c o g n i t i v e / a f f e c t i v e (e.g., k n o w l e d g e , attitudes, beliefs), o u t c o m e  19  LITERATURE REVIEW e x p e c t a t i o n s (e.g., b e s t for b a b y ) , s e l f - e f f i c a c y (e.g., c o n f i d e n c e , p r e v i o u s e x p e r i e n c e ) , b i o l o g i c a l (e.g., a g e ) o r p s y c h o s o c i a l (e.g., e m b a r r a s s m e n t ) ( W i l l i a m s et a l . , 1999). T h e s o c i o e n v i r o n m e n t a l f a c t o r s that m a y i n f l u e n c e b r e a s t - f e e d i n g duration i n c l u d e ; institutional (e.g., health c a r e p r a c t i c e s , s u p p o r t i v e w o r k p l a c e e n v i r o n m e n t s a n d p o l i c i e s ) , s o c i a l (e.g., s u p p o r t i v e p a r t n e r / f a m i l y / d y n a m i c s ) , s o c i o - d e m o g r a p h i c (e.g., e d u c a t i o n , i n c o m e , ethnicity, marital status), p h y s i c a l (e.g., d i s c o m f o r t or p a i n , t i r e d n e s s ) a n d others (e.g., d i s t a n c e f r o m work) ( W i l l l i a m s , et a l . , 1 9 9 9 ) . H o w e v e r , r e s e a r c h is l a c k i n g o n t h e internal p e r s o n a l a n d / o r s o c i o - e n v i r o n m e n t a l f a c t o r s that d e t e r m i n e s o l i d f o o d f e e d i n g p r a c t i c e s o r h o w b r e a s t - f e e d i n g p r a c t i c e s might influence solid food feeding practices. T h e W o r l d Health Organization ( W H O / U N I C E F , 1989) h a s e m p h a s i z e d the i m p o r t a n c e of s u p p o r t i v e e n v i r o n m e n t s in h o s p i t a l s a n d t h e c o m m u n i t y to p r o m o t e both i n c r e a s e d initiation a n d duration rates of b r e a s t - f e e d i n g . T o i m p l e m e n t their r e c o m m e n d a t i o n s health c a r e institutions a r e a s k e d to put in p l a c e p o l i c i e s that c o m p l y with t h e " 1 0 s t e p s to S u c c e s s f u l B r e a s t - f e e d i n g " ( W H O / U N I C E F , 1989) a n d T h e W H O International C o d e of M a r k e t i n g of B r e a s t - m i l k S u b s t i t u t e s ( W H O , 1 9 8 1 ) . A l t h o u g h m o r e s u p p o r t i v e b r e a s t - f e e d i n g w o r k e n v i r o n m e n t s ( K a t c h e r a n d L o n e s e , 1 9 8 5 ; K e a r n e y a n d C r o n e n w e t t , 1 9 9 1 ; M o r s e et a l . , 1989) a n d s o c i a l s u p p o r t ( R o u s s e a u , 1 9 8 2 ) m a y e n a b l e m o t h e r s to b r e a s t f e e d longer, a better u n d e r s t a n d i n g of h o w m o t h e r s f e e d their infants s o l i d f o o d s b e t w e e n 4 - 9 m o n t h s of a g e m a y a l s o p r o m o t e b r e a s t - f e e d i n g duration s i n c e t h e liquid a n d s o l i d f o o d p r a c t i c e s a r e s o c l o s e l y intertwined d u r i n g t h e transition p e r i o d . P r e v i o u s s t u d i e s h a v e s h o w n that b r e a s t - f e e d i n g is often d i s c o n t i n u e d e a r l y d u e to insufficient milk (Henly, 1 9 9 5 ; M a c l e a n a n d Miller, 1 9 9 8 ; W i l l i a m s et a l . , 1999) a n d m o t h e r s ' p e r c e p t i o n s of infant h u n g e r c u e s ( S c h w a r t z a n d E v e r s , 1 9 9 8 ) . A recent s t u d y in V a n c o u v e r that e x a m i n e d the f a c t o r s i n f l u e n c i n g m o t h e r s ' d e c i s i o n s to w e a n , reported that the m a i n r e a s o n s for w e a n i n g b e f o r e 3 m o n t h s w e r e t h e m o t h e r ' s c o n c e r n for the b a b y ' s nutrition, a n d b e i n g u n c o m f o r t a b l e with b r e a s t - f e e d i n g . T h e m a i n r e a s o n s for d i s c o n t i n u i n g b r e a s t - f e e d i n g at 3 to 6 m o n t h s w e r e t h e n e e d to return to w o r k , c o n c e r n a b o u t the b a b y ' s nutrition a n d c o n c e r n a b o u t milk s u p p l y . In c o n t r a s t , m o t h e r s w h o w e a n e d after 6 m o n t h s , did s o primarily b a s e d o n their n e e d to return to w o r k a n d their p e r s o n a l c h o i c e ( W i l l i a m s et a l . , 1 9 9 9 ) . T h e a v a i l a b l e d a t a a r e  20  LITERATURE REVIEW not c l e a r if the m o t h e r ' s c o n c e r n s a b o u t infant h u n g e r , nutrition a n d milk s u p p l y a r e related, in s o m e w a y , to t h e s o l i d f o o d f e e d i n g p r o c e s s rather t h a n i s s u e s s p e c i f i c to b r e a s t - f e e d i n g a l o n e . A better u n d e r s t a n d i n g of h o w m o t h e r s ' f e e d infants s o l i d f o o d s d u r i n g t h e transition p r o c e s s might further o u r u n d e r s t a n d i n g of the i n f l u e n c e of solid f o o d s o n the liquid diet, or alternately the i n f l u e n c e of liquid f o o d s o n t h e s o l i d f o o d diet. N u m e r o u s s t u d i e s h a v e u s e d primarily a quantitative a p p r o a c h (e.g., s u r v e y ) to e x a m i n e the d e m o g r a p h i c a n d s o c i a l c o r r e l a t e s of m o t h e r s ' b r e a s t - f e e d i n g b e h a v i o r s . T h e s u r v e y m e t h o d is limited in its ability to identify the m e a n i n g of c o m p l e x i s s u e s , s u c h a s b r e a s t - f e e d i n g , b e c a u s e the r e s p o n s e f o r m a t s a r e c l o s e e n d e d a n d h a v e u s u a l l y b e e n d e r i v e d f r o m the r e s e a r c h literature that is not n e c e s s a r i l y relevant to t h e c o n t e x t of the m o t h e r ' s situation. A l t h o u g h the s u r v e y m e t h o d is important for identifying d e m o g r a p h i c predictors of b r e a s t - f e e d i n g c h o i c e s , only a partial u n d e r s t a n d i n g of the ' b r e a s t - f e e d i n g ' e x p e r i e n c e c a n b e e x p e c t e d . M a c l e a n (1990), h o w e v e r , s u g g e s t s a n alternative f r a m e w o r k for thinking a b o u t the b r e a s t - f e e d i n g e x p e r i e n c e . U s i n g e x p e r i e n t i a l l y f o c u s e d r e s e a r c h , m o t h e r s t a l k e d in-depth a b o u t the variety of r e a s o n s that c o n t r i b u t e d to their d e c i s i o n to w e a n early. O n e c o m p l e x s e t of f a c t o r s that e v o l v e d w a s l i n k e d to the overwhelming  experience  of having  s e t of f a c t o r s w a s l i n k e d to t h e cultural s o c i a l v a l u e s ) . L a s t l y , changes  a baby (turbulent e m o t i o n s a n d vulnerability).  Another  context (the c u m u l a t i v e w o r k of m o t h e r i n g a n d conflicting  in self identity (self worth, s o c i a l i s o l a t i o n , f e e l i n g s of r e w a r d a n d  a n x i e t y , p h y s i c a l d i s c o m f o r t o r p a i n , s e n s e of time) w e r e c l o s e l y linked to m o t h e r s ' b r e a s t - f e e d i n g e x p e r i e n c e s a n d e a r l y w e a n i n g . T h e s e t h e m e s m a y a l s o i m p a c t the 'transition e x p e r i e n c e ' a n d i n f l u e n c e the a g e s o l i d f o o d s a r e i n t r o d u c e d , a s well a s h o w s o l i d f o o d s a r e f e d to 4 - 9 m o n t h s old infants. F u r t h e r a d v a n c e s in u n d e r s t a n d i n g w e a n i n g p r a c t i c e s might c o m e f r o m a d e e p e r u n d e r s t a n d i n g of h o w m o t h e r s e x p e r i e n c e t h e s o l i d f o o d f e e d i n g p r o c e s s .  2.3.  Infant feeding guidelines R e c e n t l y , t h r e e e x p e r t g r o u p s : t h e C a n a d i a n P a e d i a t r i c S o c i e t y Nutrition C o m m i t t e e ,  Dietitians of C a n a d a a n d H e a l t h C a n a d a h a v e p r e p a r e d a N a t i o n a l s t a t e m e n t o n nutrition for h e a l t h y t e r m infants f r o m birth to 2 4 m o n t h s of a g e ( C a n a d i a n P a e d i a t r i c S o c i e t y , 1998). It is  21  LITERATURE REVIEW important to note, h o w e v e r , that the infant f e e d i n g r e c o m m e n d a t i o n s are b a s e d o n scientific e v i d e n c e w h e n it is a v a i l a b l e , but a r e o t h e r w i s e b a s e d o n " a c c e p t e d c o m m o n p r a c t i c e s " . T h e g u i d e l i n e s p r o v i d e health c a r e p r o f e s s i o n a l s with current reliable nutrition information o n b r e a s t f e e d i n g , alternate m i l k s , transition to s o l i d f o o d s , the p r e v e n t i o n of iron d e f i c i e n c y a n e m i a a n d other t o p i c s ( C P S , 1 9 9 8 ) . T h e g u i d e l i n e s a r e u s e d b y m a n y s e c t o r s , i n c l u d i n g industry for p r e p a r a t i o n of e d u c a t i o n m a t e r i a l s a n d c o m m e n t s o n f o o d p a c k a g i n g . T h e p o p u l a r p r e s s a l s o u s e s this i n f o r m a t i o n (i.e., p a r e n t i n g m a g a z i n e s ) . H o s p i t a l s a n d p h y s i c i a n o f f i c e s , a s w e l l a s public health d e p a r t m e n t s p r o v i d e this information for m o t h e r s . A s a result, m o t h e r s r e c e i v e infant f e e d i n g information t h r o u g h m a n y c h a n n e l s . H o w e v e r , t h e infant f e e d i n g g u i d e l i n e s d o not f o c u s o n t h e p r a c t i c a l i s s u e s a r o u n d h o w to f e e d s o l i d f o o d s . W i t h r e g a r d s to t h e transition to s o l i d f o o d s , the current f e e d i n g g u i d e l i n e s for h e a l t h y t e r m infants ( C a n a d i a n P a e d i a t r i c S o c i e t y , 1 9 9 8 ) s t a t e that " i n f a n t s b e t w e e n 4 a n d 6 m o n t h s of a g e a r e p h y s i o l o g i c a l l y a n d d e v e l o p m e n t a l l y r e a d y for n e w f o o d s , textures a n d m o d e s of f e e d i n g " . T h u s , two s p e c i f i c r e c o m m e n d a t i o n s a r e g i v e n . M o t h e r s a r e r e c o m m e n d e d to introduce c o m p l e m e n t a r y f o o d s at 4 to 6 m o n t h s of a g e to m e e t t h e infant's i n c r e a s i n g nutritional r e q u i r e m e n t s a n d for d e v e l o p m e n t a l n e e d s . S e c o n d , to p r e v e n t iron d e f i c i e n c y , iron-containing f o o d s s u c h a s iron-fortified c e r e a l s a r e r e c o m m e n d e d a s t h e first f o o d s . In a d d i t i o n , t h e w o r k i n g g r o u p r e c o m m e n d s that t h e e a r l y u s e of w e a n i n g f o o d s , that is prior to 4 m o n t h s of a g e , m a y i n c r e a s e t h e risk of iron d e p l e t i o n a n d a n e m i a s i n c e iron a b s o r p t i o n f r o m h u m a n milk is d e p r e s s e d w h e n t h e milk is in c o n t a c t with o t h e r f o o d s in t h e p r o x i m a l s m a l l b o w e l . T h i s s t a t e m e n t i m p l i e s that t h e timing of f e e d i n g b r e a s t milk a n d s o l i d f o o d s is important to iron a b s o r p t i o n . F u r t h e r , with r e g a r d s to t h e p r e v e n t i o n of iron d e f i c i e n c y a n e m i a , t h e g u i d e l i n e s s t a t e "iron d e f i c i e n c y is p r e v e n t a b l e t h r o u g h a p p r o p r i a t e f e e d i n g c h o i c e s " . C o n s e q u e n t l y , six r e c o m m e n d a t i o n s a r e g i v e n , t h r e e p e r t a i n i n g to t h e p r i m a r y milk s o u r c e , two r e g a r d i n g the a g e of introduction a n d duration of f e e d i n g iron c o n t a i n i n g s o l i d f o o d s , a n d o n e refers to s c r e e n i n g for IDA a n d s u p p l e m e n t a t i o n with m e d i c i n a l iron. T h e first r e c o m m e n d a t i o n is to c o n t i n u e e x c l u s i v e b r e a s t - f e e d i n g for at l e a s t 4 m o n t h s . T h e g u i d e l i n e s r e c o m m e n d that m o t h e r s introduce c o m p l e m e n t a r y f o o d s c o n t a i n i n g iron at 4 to 6 m o n t h s of a g e . T h e third r e c o m m e n d a t i o n a d v i s e s  22  LITERATURE REVIEW that t h e preferred b r e a s t - m i l k substitute for infants w h o a r e not b r e a s t - f e d or w h o a r e partially b r e a s t - f e d is iron-fortified infant f o r m u l a s . T h e g u i d e l i n e s r e c o m m e n d d e l a y i n g the introduction of w h o l e c o w ' s milk until t h e infant is 9 to 1 2 m o n t h s of a g e . T h e fifth r e c o m m e n d a t i o n is to c o n t i n u e to offer iron-fortified f o o d s b e y o n d 1 y e a r of a g e to p r o v i d e sufficient dietary iron for the infant. T h e last r e c o m m e n d a t i o n is that w h e r e i n f o r m e d p a r e n t s c h o o s e not to a d h e r e to t h e s e r e c o m m e n d a t i o n s , t h e infant s h o u l d b e s c r e e n e d for a n e m i a at 6 to 8 m o n t h s of a g e a n d p r o v i d e d with m e d i c i n a l iron d r o p s , if n e c e s s a r y ( C P S , 1 9 9 8 ) . In a d d i t i o n to t h e N a t i o n a l g u i d e l i n e s , P r o v i n c i a l infant f e e d i n g g u i d e l i n e s h a v e a l s o b e e n d e v e l o p e d . T h e current g u i d e l i n e s for British C o l u m b i a ( B . C . M i n i s t r y of H e a l t h , 1 9 9 6 ) , r e c o m m e n d f e e d i n g s o l i d f o o d s 1 - 2 t i m e s p e r d a y , f r o m 4 to 6 m o n t h s of a g e starting with 1 t e a s p o o n of iron-fortified c e r e a l a n d i n c r e a s i n g to 4 t a b l e s p o o n s p e r d a y . F r o m 6 to 9 m o n t h s , m o t h e r s a r e instructed to f e e d their infant s o l i d f o o d s 3 - 4 t i m e s p e r d a y . S p e c i f i c a l l y , t h e g u i d e l i n e s r e c o m m e n d to f e e d infant c e r e a l in the a m o u n t of 4 to 8 t a b l e s p o o n s daily, a s w e l l a s introduce other iron c o n t a i n i n g f o o d s s u c h a s m e a t , f i s h , a n d poultry starting at 6 m o n t h s of a g e (Appendix A). T h e w e a n i n g r e c o m m e n d a t i o n s c a n b e c o n s i d e r e d in t h r e e o v e r l a p p i n g p e r i o d s : 1) the exclusive modified  milk (breast or formula)  feeding  period, 2) the weaning  period a n d 3) the p e r i o d of a  adult diet ( C a m e r o n et a l , 1 9 9 0 ; E S P G A N , 1 9 8 1 ; W h a r t o n , 1 9 8 9 ; W H O , 1988). T h e  c o n c e p t of ' o v e r l a p p i n g p e r i o d s ' is illustrated b y listing the p r o g r e s s i o n of f o o d s r e c o m m e n d e d for introduction into the infant diet, a c c o r d i n g to a g e of the infant (i.e., 0 to 2 4 m o n t h s ) . T h e m a i n p u b l i c h e a l t h m e s s a g e s c o n v e y e d in t h e infant f e e d i n g r e c o m m e n d a t i o n s a r e a) w h e n to introduce s o l i d f o o d s , b) w h a t f o o d s to i n t r o d u c e a n d c) the f e e d i n g p r o g r e s s i o n . T h e f e e d i n g p r o g r e s s i o n refers to i n c r e a s i n g t h e quantity a n d v a r i e t y of s o l i d f o o d s that t h e infant e a t s s o b y a b o u t 1 y e a r of a g e t h e infant is c o n s u m i n g a ' m o d i f i e d ' adult diet. H o w e v e r , r e s e a r c h is l a c k i n g o n h o w m o t h e r s in the n a t u r a l setting f e e d their infants s o l i d f o o d s a n d w h a t d e t e r m i n e s their feeding practices. S o m e light m a y b e s h e d o n t h e c a u s e s of the p r e v a l e n c e of iron d e f i c i e n c y a m o n g infants b y e x p l o r i n g d e t e r m i n a n t s of s o l i d f o o d f e e d i n g p r a c t i c e s that m a y i n f l u e n c e the infant's  23  LITERATURE REVIEW c o n s u m p t i o n of iron-fortified c e r e a l s . R e s e a r c h identifying t h e k e y b e h a v i o r a l f a c t o r s that i n f l u e n c e t h e c o n s u m p t i o n of iron c o n t a i n i n g s o l i d f o o d s b y infants a n d thus p o s s i b l y contributing to the d e v e l o p m e n t of iron d e f i c i e n c y in t h e s e c o n d 6 m o n t h s of life is l a c k i n g . T h e c o n c e p t u a l f r a m e w o r k s n e e d e d for this t y p e of b e h a v i o r a l r e s e a r c h h a v e not yet b e e n fully articulated in the literature. Further, s o l i d f o o d f e e d i n g p r a c t i c e s h a v e not b e e n s t u d i e d u s i n g a qualitative a p p r o a c h a n d , t h e r e f o r e , t h e infant f e e d i n g literature reflects this g a p in k n o w l e d g e . 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 build f r a m e w o r k s that c a n facilitate the investigation a n d u n d e r s t a n d i n g of important b e h a v i o r a l a n d c o g n i t i v e f a c t o r s that i n f l u e n c e the f e e d i n g of s o l i d f o o d s , particularly t h o s e high in iron, to infants d u r i n g t h e transition p r o c e s s . R e s e a r c h to g a i n a better u n d e r s t a n d i n g of m o t h e r s ' s o l i d f o o d f e e d i n g p r a c t i c e s d u r i n g the transition p e r i o d is, t h e r e f o r e , n e e d e d to a d d r e s s the g a p s in the current r e s e a r c h literature.  24  DESIGN AND METHODS  Chapter III  3.1.  Introduction to qualitative research design A n e x p l o r a t o r y r e s e a r c h d e s i g n w a s u s e d to i n v e s t i g a t e m o t h e r s ' c o m p l e m e n t a r y s o l i d  f o o d f e e d i n g e x p e r i e n c e s . T h i s r e s e a r c h d e s i g n w a s c h o s e n b e c a u s e qualitative r e s e a r c h c a n e x p a n d k n o w l e d g e a n d t h e o r y a b o u t t h e infant s o l i d f o o d f e e d i n g p r o c e s s in a natural c o n t e x t t h r o u g h l e a r n i n g a b o u t m o t h e r s ' p e r s o n a l d a y - t o - d a y e x p e r i e n c e s . Additionally, qualitative r e s e a r c h h a s t h e m o s t potential to identify a n d d e v e l o p relevant c o n c e p t s o n w h i c h to build h y p o t h e s e s that a r e t i m e a n d c o n t e x t b o u n d . Q u a l i t a t i v e inquiry i n c r e a s e s u n d e r s t a n d i n g of participants' p e r c e p t i o n s a n d e x p e r i e n c e s in their natural setting, providing r e s e a r c h f i n d i n g s that a r e relevant a n d p r a c t i c a l . A s a result, f i n d i n g s c a n b e v e r y u s e f u l for informing nutrition, dietetic a n d public h e a l t h n u r s i n g p r a c t i c e . Further, qualitative r e s e a r c h c a n b e u s e d to c r e a t e n e w d a t a g a t h e r i n g t e c h n i q u e s to g u i d e future r e s e a r c h . A qualitative r e s e a r c h d e s i g n h a s m a j o r d i f f e r e n c e s in m e t h o d o l o g i c a l a s s u m p t i o n s c o m p a r e d with a quantitative r e s e a r c h d e s i g n ( C r e s w e l l , 1 9 9 4 ; L i n c o l n a n d G u b a , 1 9 8 5 ) . Briefly, qualitative r e s e a r c h is descriptive  in that the inquirer is i n t e r e s t e d in u n d e r s t a n d i n g h o w  i n d i v i d u a l s m a k e s e n s e of their p e r s o n a l e x p e r i e n c e s , t h e c o n d i t i o n s that i n f l u e n c e their a c t i o n s , a n d the c o n s e q u e n c e s of their a c t i o n s . T h e d a t a a r e not, in t h e c o n v e n t i o n a l s e n s e , quantifiable. T h e o r y or h y p o t h e s e s in qualitative r e s e a r c h a r e not e s t a b l i s h e d a priori s i n c e the f o c u s of this r e s e a r c h is not to verify o r falsify h y p o t h e s e s u s i n g statistical f o r m u l a s . Instead, t h e p r o c e s s of qualitative r e s e a r c h is inductive  a n d emergent.  It is i n d u c t i v e in that the inquirer, a s the p r i m a r y  d a t a c o l l e c t i o n a n d a n a l y s i s tool, a t t e m p t s to build a b s t r a c t i o n s , c o n c e p t s , h y p o t h e s e s a n d t h e o r i e s that a r e t i m e a n d c o n t e x t b o u n d . It is e m e r g e n t in that the r e s e a r c h e r ' s interpretations (findings) a r e a r e c o n s t r u c t i o n built f r o m multiple v o i c e s ( A n n e l l s , 1 9 9 6 ; L i n c o l n a n d G u b a , 1 9 8 5 ; M e r r i a m , 1 9 8 8 ) . B e a r i n g in m i n d , that t h e r e s e a r c h e r is t h e p r i m a r y d a t a c o l l e c t i o n a n d a n a l y s i s instrument, qualitative inquiry is value-bound  ( M u n h a l l a n d B o y d , 1993). A 'reflexive' journal of  e v o l v i n g t h e o r e t i c a l t h i n k i n g a b o u t the d a t a is u s e d to u n d e r s t a n d h o w p e r s o n a l e x p e r i e n c e s m a y  25  DESIGN AND METHODS s h a p e the v a l u e s a n d b i a s e s brought to the r e s e a r c h t h r o u g h t h e 'instrument' itself. T h e a s s u m p t i o n h e r e is that t h e r e s e a r c h e r ' s p e r s o n a l b i a s e s c a n not b e e l i m i n a t e d in qualitative r e s e a r c h , rather their i n f l u e n c e o n the d a t a interpretations c a n b e better u n d e r s t o o d a n d reflected u p o n . L a s t l y , the critical i s s u e of j u d g i n g the r e s e a r c h p r o c e s s a n d p r o d u c t quality differs b e t w e e n qualitative a n d quantitative r e s e a r c h . T h e f o u r m a j o r criteria u s e d in qualitative r e s e a r c h for e s t a b l i s h i n g t r u s t w o r t h i n e s s a r e credibility, transferability, d e p e n d a b i l i t y a n d confirmability ( L i n c o l n a n d G u b a , 1 9 8 5 ) . T h e s e criteria a r e u s e d i n s t e a d of the traditional validity a n d reliability m e a s u r e s u s e d in quantitative r e s e a r c h b e c a u s e the d a t a g e n e r a t e d a n d t h e a n a l y s i s p r o c e d u r e s in the qualitative r e s e a r c h d e s i g n s a r e d r a m a t i c a l l y different f r o m that of quantitative r e s e a r c h . G r o u n d e d t h e o r y m e t h o d o l o g y is u s e d to c o l l e c t a n d a n a l y z e d a t a o n h u m a n b e h a v i o r . B e c a u s e of t h e a b s e n c e of p u b l i s h e d r e s e a r c h o n m o t h e r s ' s o l i d f o o d f e e d i n g p r a c t i c e s d u r i n g t h e transition p r o c e s s , the v a r i a b l e s relevant to the infant f e e d i n g c o n c e p t s h a v e not yet b e e n identified. T h e r e f o r e , t h e o r y testing is not the b e s t a p p r o a c h . B e c a u s e of its u n i q u e d a t a c o l l e c t i o n a n d a n a l y s i s p r o c e d u r e s , t h e g r o u n d e d t h e o r y m e t h o d h a s the m o s t potential to identify c o n c e p t s a n d d e v e l o p t h e o r y to e x p l a i n b a s i c f e e d i n g p r a c t i c e s a n d patterns c o m m o n in m o t h e r s ' d a y - t o - d a y activities. T h i s is important, b e c a u s e it is p o s s i b l e that m o t h e r s ' s o l i d f o o d f e e d i n g p r a c t i c e s a n d f e e d i n g p a t t e r n s o v e r t i m e m a y b e related to t h e infant's c o n s u m p t i o n of iron containing solid foods. T h e g r o u n d e d t h e o r y m e t h o d h a s its roots in the s o c i a l s c i e n c e s , s p e c i f i c a l l y in the s y m b o l i c interaction tradition of s o c i a l p s y c h o l o g y a n d s o c i o l o g y . G r o u n d e d t h e o r y a s a m e t h o d o l o g y w a s originally d e v e l o p e d b y two s o c i o l o g i s t s , B a r n y G l a s e r a n d A n s l e m S t r a u s s , a n d p u b l i s h e d initially in the s e m i n a l w o r k , T h e D i s c o v e r y of G r o u n d e d T h e o r y ( G l a s e r a n d S t r a u s s , 1 9 6 7 ) . A g a i n , t h e p r i m a r y a i m of g r o u n d e d t h e o r y is to g e n e r a t e e x p l a n a t o r y t h e o r y that furthers the u n d e r s t a n d i n g of s o c i a l a n d p s y c h o l o g i c a l p h e n o m e n a . T h u s , g r o u n d e d t h e o r i e s a r e s y s t e m a t i c s t a t e m e n t s of p l a u s i b l e r e l a t i o n s h i p s ( D e n z i n a n d L i n c o l n , 1 9 9 4 ; H u t c h i n s o n , 1 9 9 3 ) . T h e g r o u n d e d t h e o r y p r o c e d u r e s p r o v i d e a highly s y s t e m a t i c r e s e a r c h a p p r o a c h for the c o l l e c t i o n a n d a n a l y s i s of qualitative d a t a that differs s o m e w h a t from other qualitative a p p r o a c h e s . First, g r e a t e r e m p h a s i s is p l a c e d o n t h e d e v e l o p m e n t of t h e o r y ( h y p o t h e s i s ) .  26  DESIGN A N D M E T H O D S S e c o n d , there is a n explicit m a n d a t e to strive t o w a r d verification of the resulting h y p o t h e s e s ( s t a t e m e n t s of r e l a t i o n s h i p s b e t w e e n c o n c e p t s ) . T h i r d , verification is e m p h a s i z e d t h r o u g h o u t the r e s e a r c h p r o c e s s , rather t h a n in s u b s e q u e n t s t u d i e s . 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 ( G l a s e r , 1 9 7 8 ) a i d s in identifying a n d stating p l a u s i b l e r e l a t i o n s h i p s a m o n g the c a t e g o r i e s that h a v e b e e n d i s c o v e r e d . T h e s e r e l a t i o n s h i p s a r e v e r i f i e d with t h e original interview d a t a . F i n a l l y , within the e m e r g i n g d a t a s e t , e m p h a s i s is p l a c e d o n d e v e l o p i n g ' c o n c e p t u a l l y d e n s e ' t h e o r y v e r s u s d e s c r i p t i o n . C o n c e p t u a l d e n s i t y refers to e n h a n c e d c o n c e p t d e v e l o p m e n t a n d t h e s u b s e q u e n t integration of r e l a t i o n s h i p s b e t w e e n t h e c o n c e p t s ( D e n z i n a n d L i n c o l n , 1 9 9 4 ; S t r e u b e r t a n d C a r p e n t e r , 1 9 9 5 ) . T h e m o s t d i s t i n g u i s h i n g c h a r a c t e r i s t i c s of t h e g r o u n d e d t h e o r y p r o c e d u r e s a r e : t h e c o n s t a n 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 , i n c l u d i n g t h e s y s t e m a t i c a s k i n g of g e n e r a t i v e a n d c o n c e p t - r e l a t e d q u e s t i o n s , s y s t e m a t i c c o d i n g p r o c e d u r e s , g u i d e l i n e s for attaining c o n c e p t u a l (not m e r e l y d e s c r i p t i v e ) " d e n s i t y , variation, c o n c e p t u a l integration, a n d s u b s e q u e n t t h e o r e t i c a l s a m p l i n g . Integration, h e r e , m e a n s s p e c i f y i n g c o n d i t i o n s a n d c o n s e q u e n c e s of t h e p h e n o m e n o n b e i n g e x p l o r e d ( S t r a u s s a n d C o r b i n , 1 9 9 0 ) . T w o m o d e l s that a r e f u n d a m e n t a l t o d a t a a n a l y s i s a r e u s e d in t h e g r o u n d e d t h e o r y m e t h o d . T h e first is r e f e r r e d to a s a c o n c e p t - i n d i c a t o r m o d e l . A s illustrated in F i g u r e 3 , t h e m o d e l a i d s in t h e g e n e r a t i o n of c o n c e p t u a l c o d e s . In o r d e r to build a c o n c e p t a n d its p r o p e r t i e s s l o w l y f r o m t h e d a t a , the i n d i c a t o r s a r e c o n s t a n t l y c o m p a r e d to e a c h other a n d to t h e e m e r g i n g concept o n c e the conceptual c o d e has b e e n generated.  Legend  CONCEPT  I,  I  2  h  J  4  )  X  5  I,, l ...- Indicators (chunks of data such as words, phrases) are compared to each other and the concept that is developing. 2  X  6  Indicators F i g u r e 3. C o n c e p t - Indicator M o d e l ( a d a p t e d f r o m G l a s e r , 1 9 7 8 , 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. T h e model is illustrated in Figure 4. T h e 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. T h e 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. T h e consequences are the outcomes or results of the action and interaction. T h e covariance is the individual variation between the people. T h e 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 Covariance  t T  t ^ :  Contingent  Figure 4. T h e Causal-Consequence Model (adapted from Glaser, 1978  28  p.74)  DESIGN AND METHODS T h e 4 criteria s u g g e s t e d for e s t a b l i s h i n g t r u s t w o r t h i n e s s in qualitative r e s e a r c h a r e ; credibility, transferability, d e p e n d a b i l i t y a n d confirmability (Lincoln a n d G u b a , 1 9 8 5 ) . T h e credibility of interpreting t h e r e s e a r c h d a t a is e n h a n c e d t h r o u g h s e v e r a l p r o c e d u r e s . A reflexive j o u r n a l that i n c l u d e s a d e t a i l e d d i a l o g u e a b o u t t h e m e a n i n g s of the d a t a b e i n g a n a l y z e d a n d a d e s c r i p t i o n of h o w t h e a n a l y s i s e v o l v e d , with the c o d i n g p r o c e d u r e s , g i v e s s o m e insight into h o w f i n d i n g s w e r e interpreted o v e r t h e a n a l y s i s p r o c e s s . A j o u r n a l a l s o a i d s in d e v e l o p i n g t h e a n a l y s t ' s skills (i.e., t h e o r e t i c a l sensitivity). E x t e r n a l c h e c k s d o n e during the a n a l y s i s of t h e d a t a a i d in ' b a l a n c i n g ' interpretations o n c o n c e p t s , c a t e g o r i e s a n d the relationships that a r e c o n c e p t u a l i z e d . F e e d b a c k f r o m p e e r s o n d a t a interpretation i m p r o v e s the c o n s t r u c t i o n s . N e g a t i v e c a s e s of s i t u a t i o n s , e v e n t s o r e x p e r i e n c e s s h o u l d b e identified throughout t h e a n a l y s i s . T h e identification of n e g a t i v e c a s e s k e e p s t h e a n a l y s i s b r o a d a n d facilitates the identification of c o n t e x t u a l f a c t o r s that m a y i n f l u e n c e t h e p h e n o m e n o n that w o u l d o t h e r w i s e b e lost. P e r s i s t e n t , s y s t e m a t i c a n a l y s i s p r o c e d u r e s a r e e s s e n t i a l to a l l o w not o n l y identification of t h e m o s t relevant i s s u e s , but for t h e m to b e a n a l y z e d in d e t a i l . In t h i s w a y , s c o p e a n d d e p t h of a n a l y s i s c a n b e a c h i e v e d . In-depth i n t e r v i e w s p r o v i d e a m p l e d a t a to o b t a i n c o n c e p t u a l d e n s i t y of t h e e m e r g i n g c a t e g o r i e s , but it is t h e a n a l y s t , w h o b y u s i n g a s y s t e m a t i c p r o c e d u r e d i s c o v e r s m e a n i n g f r o m t h e d a t a (reconstruction of multiple v o i c e s ) . In qualitative r e s e a r c h , transferability is t h e t e r m u s e d i n s t e a d of external validity to d e s c r i b e t h e d e g r e e to w h i c h t h e f i n d i n g s c a n b e a p p l i e d in other settings, or to o t h e r g r o u p s of p e o p l e . S i n c e it is not p o s s i b l e in qualitative r e s e a r c h to state statistical c o n f i d e n c e limits to r e p r e s e n t t h e e x t e r n a l validity of results, 'thick' d e s c r i p t i o n s of the interview d a t a a n d t h e participant c h a r a c t e r i s t i c s a r e p r o v i d e d . T h i s a l l o w s t h e a u d i e n c e to j u d g e t h e transferability of the s t u d y f i n d i n g s to o t h e r s i t u a t i o n s or p o p u l a t i o n s . T h e third criteria p r o p o s e d b y L i n c o l n a n d G u b a (1985) is d e p e n d a b i l i t y . T o e n s u r e findings a r e d e p e n d a b l e a n e v a l u a t i o n of the r e s e a r c h p r o c e s s is p r o p o s e d . A s e r i e s of d o c u m e n t a t i o n p r o c e d u r e s a r e f o l l o w e d to a i d in the d a t a o r g a n i z a t i o n , the a n a l y s i s p r o c e d u r e s a n d the a n a l y s i s itself. T h e d e p e n d a b i l i t y . o f f i n d i n g s c a n b e j u d g e d f r o m t h e s e p r o c e d u r e s .  29  DESIGN AND METHODS T h e a i m of the confirmability criteria is to e v a l u a t e t h e r e s e a r c h product, the d a t a , findings, interpretations a n d r e c o m m e n d a t i o n s . T h e d a t a o b t a i n e d f r o m in-depth interviews a r e v e r y 'rich' a n d t h u s , t h e d e s c r i p t i o n s a n d c o n c e p t u a l i z a t i o n s of h u m a n e x p e r i e n c e s s h o u l d reflect this r i c h n e s s . T h e results of a qualitative s t u d y c a n b e j u d g e d in light of the n u m e r o u s p r o c e d u r e s f o l l o w e d to p r o m o t e high quality d a t a m a n a g e m e n t , d a t a a n a l y s i s a n d interpretive integration. S t r a u s s a n d C o r b i n (1990) h a v e outlined a d o u b l e s e t of criteria f o r j u d g i n g a g r o u n d e d t h e o r y study. T h e g u i d e l i n e s t h e s e a u t h o r s s u g g e s t c e n t e r a r o u n d two c o m p o n e n t s , the r e s e a r c h p r o c e s s a n d t h e e m p i r i c a l g r o u n d i n g of the t h e o r e t i c a l f i n d i n g s . Briefly, S t r a u s s a n d C o r b i n (1990) e v a l u a t e t h e r e s e a r c h p r o c e s s t h r o u g h e x a m i n a t i o n of the s a m p l e s e l e c t i o n criteria, c a t e g o r i e s that e m e r g e d a n d h o w t h e y w e r e f o r m e d , t h e o r e t i c a l s a m p l i n g p r o c e d u r e s , h y p o t h e s i s f o r m a t i o n a n d t e s t i n g , a n d c o r e c a t e g o r y s e l e c t i o n . In a d d i t i o n , the g r o u n d i n g of the t h e o r e t i c a l findings is b a s e d o n t h e e x a m i n a t i o n of the d e g r e e to w h i c h t h e identified c o n c e p t s a r e g r o u n d e d f r o m the d a t a , rather t h a n f r o m c o n j e c t u r e . T h e d e v e l o p m e n t of c o n c e p t u a l l i n k a g e s , t h e i n c l u s i o n of variation into t h e theory, a n d e m p h a s i s o n ' p r o c e s s ' that identifies a n d s p e c i f i e s c h a n g e to build the c o n c e p t u a l d e n s i t y n e e d e d to g o b e y o n d d e s c r i p t i v e a n a l y s i s , a r e all critical to a g r o u n d e d theory s t u d y . T h e d a t a c a n a l s o b e a n a l y z e d m a c r o s c o p i c a l l y . T h i s i n c l u d e s s o m e d e g r e e of a n a l y s i s of t h e g r e a t e r s o c i a l , e n v i r o n m e n t a l a n d institutional f a c t o r s that i n f l u e n c e i n d i v i d u a l b e h a v i o r . L a s t l y , t h e r e s e a r c h is e v a l u a t e d o n if, o r to w h a t extent the findings a p p e a r significant f r o m the p e r s p e c t i v e of contribution to k n o w l e d g e , t h e o r y , tool d e v e l o p m e n t , p r a c t i c e or other relevant e n d p o i n t s ( L i n c o l n , 1 9 9 5 ) .  3.2.  Design and Methods  A q u a l i t a t i v e r e s e a r c h d e s i g n w a s u s e d to s t u d y m o t h e r s ' c o m p l e m e n t a r y s o l i d f o o d f e e d i n g p r a c t i c e s d u r i n g t h e liquid to s o l i d f o o d transition p e r i o d that u s u a l l y o c c u r s w h e n the infant is 4 - 9 m o n t h s of a g e . A g r o u n d e d t h e o r y m e t h o d o l o g y w a s u s e d to g u i d e d a t a c o l l e c t i o n a n d a n a l y s i s of h u m a n b e h a v i o r . In addition to the i n t e r v i e w s , a n infant-feeding q u e s t i o n n a i r e  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. T h e 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 o n l y fluent in E n g l i s h a n d in-depth interviewing w a s a p r i m a r y c o m p o n e n t of the r e s e a r c h design.  3.2.3. Participant recruitment P u b l i c health n u r s e s facilitating infant g r o u p c l i n i c s w e r e a p p r o a c h e d f a c e - t o - f a c e a b o u t the r e s e a r c h project a n d w e r e a s k e d to h e l p recruit m o t h e r s w h o met the s t u d y i n c l u s i o n criteria. P u b l i c health n u r s e s i n t r o d u c e d t h e r e s e a r c h s t u d e n t to m o t h e r s w h o w e r e a t t e n d i n g a n infant g r o u p clinic a n d w h o h a d infants within t h e s e l e c t i o n criteria. T h e student t h e n briefly e x p l a i n e d t h e r e s e a r c h project. If t h e m o t h e r w a s i n t e r e s t e d in participating, s h e w a s a s k e d for h e r h o m e p h o n e n u m b e r for t h e s t u d e n t to c o n t a c t h e r later. T h e potential participants w e r e t e l e p h o n e d a n d t h e s t u d y p r o c e d u r e s w e r e e x p l a i n e d . A recruitment c h e c k l i s t w a s u s e d to facilitate a p p r o p r i a t e participant s e l e c t i o n ( A p p e n d i x D ) . Interview s e s s i o n s w e r e s c h e d u l e d at t h e participant's c o n v e n i e n c e . T w e l v e m o t h e r s p a r t i c i p a t e d in the study. T w o m o t h e r s w e r e recruited through p e r s o n a l referral. T e n m o t h e r s w e r e recruited with the a s s i s t a n c e of public health n u r s e s at c o m m u n i t y c e n t e r s . F o u r recruitment s i t e s w e r e u s e d for this study. F r o m the 10 m o t h e r s w h o w e r e recruited f r o m t h e p u b l i c h e a l t h c o m m u n i t y c e n t e r s , 2 w e r e f r o m t h e F a l s e C r e e k C o m m u n i t y C e n t e r , 3 w e r e f r o m the S t . J a m e s C o m m u n i t y C e n t e r , a n d 5 m o t h e r s w e r e recruited f r o m the U . B . C . Infant Drop-In C e n t e r . T h e r e w e r e n o participants f r o m t h e fourth site: U . B . C Little G o s l i n g s D a y c a r e .  A n additional 'potential' participant, recruited f r o m the U . B . C . Infant  Drop-In, d e c l i n e d after s e v e r a l r e s c h e d u l e d interview t i m e s .  3.3.  Data Collection  D a t a w e r e c o l l e c t e d u s i n g two m e t h o d s ; interviews a n d q u e s t i o n n a i r e s . T h e total interview s e s s i o n t o o k f r o m 6 5 to 1 2 0 m i n u t e s to c o m p l e t e , but a v e r a g e d a b o u t 9 0 m i n u t e s in length. First, e a c h participant c o m p l e t e d a 3 0 - 4 5 m i n u t e t a p e - r e c o r d e d s e m i - s t r u c t u r e d interview. P a r t i c i p a n t s t h e n c o m p l e t e d a s t r u c t u r e d interview (infant f e e d i n g p r a c t i c e s q u e s t i o n n a i r e ) that t o o k a n a d d i t i o n a l 3 0 - 4 5 m i n u t e s . T h e infant f e e d i n g p r a c t i c e s q u e s t i o n n a i r e w a s o n l y fully d e v e l o p e d after t h e third interview , t h u s o n l y t h e last 9 participants c o m p l e t e d the q u e s t i o n n a i r e .  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 participant filling out a confidential p e r s o n a l a n d d e m o g r a p h i c q u e s t i o n n a i r e that took a further 5 - 1 0 m i n u t e s . A l l of the interviews, e x c e p t o n e , w e r e c o m p l e t e d in t h e m o t h e r ' s h o m e . O n e interview w a s c o m p l e t e d at a quiet c o f f e e s h o p selected 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 r e s e a r c h topic. T h e w a r m - u p d i s c u s s i o n is illustrated in t h e interview g u i d e b e l o w . T h e m o t h e r s w e r e e a c h a s k e d 5 g e n e r a l q u e s t i o n s that g u i d e d t h e c o n v e r s a t i o n o n t o the r e s e a r c h topic ( M u n h a l l a n d B o y d , 1 9 9 3 ) . T h e q u e s t i o n s w e r e d e s i g n e d to o b t a i n information a b o u t t h e m o t h e r ' s s o l i d f o o d f e e d i n g p r a c t i c e s (i.e., h e r a c t i o n s ) , a n d o n h e r p e r c e p t i o n s (her c o n s t r u c t i o n s ) 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 y o u r b a b y b o r n ? I a m interested in u n d e r s t a n d i n g m o r e a b o u t t h e infant w e a n i n g p r o c e s s , c a n y o u tell m e a b o u t y o u r e x p e r i e n c e s f e e d i n g your baby solid foods).  Guiding Questions:  1.  C a n y o u tell m e a b o u t w h a t t h e infant w e a n i n g p r o c e s s is l i k e ? O r tell m e a b o u t y o u r e x p e r i e n c e with t h e infant w e a n i n g p r o c e s s (what is it like)?  2.  W h a t difficulties h a v e y o u e n c o u n t e r e d (if a n y ) ? i.e. F a m i l y / f r i e n d s / b a b y / h e a l t h c a r e professionals  3.  W h a t is w o r k i n g w e l l for y o u ?  4.  W h a t w o u l d y o u tell a n e w m o t h e r a b o u t the w e a n i n g p r o c e s s ?  5.  W h a t w o u l d y o u tell health c a r e p r o f e s s i o n a l s a b o u t the w e a n i n g p r o c e s s ?  33  DESIGN AND METHODS 3.3.2. Infant feeding practices questionnaire  T h e q u e s t i o n n a i r e w a s d e v e l o p e d u s i n g c o n c e p t s from the r e v i e w of current literature a n d t h r o u g h f e e d b a c k f r o m 4 infant nutrition a n d / o r s u r v e y d e s i g n e x p e r t s . T h e f e e d b a c k provided b y t h e s e e x p e r t s w a s u s e d to r e v i s e t h e q u e s t i o n n a i r e . T h r e e m o t h e r s not i n v o l v e d in this s t u d y p r o v i d e d f e e d b a c k o n t h e clarity of the q u e s t i o n s a n d t h e format. T w o q u e s t i o n f o r m a t s w e r e d e v e l o p e d for the q u e s t i o n n a i r e . S i n g l e r e s p o n s e a n d short a n s w e r q u e s t i o n s w e r e u s e d to obtain d a t a o n the m o t h e r ' s p r e s e n t f e e d i n g p r a c t i c e s a n d p e r c e p t i o n s . O t h e r q u e s t i o n s w e r e d e v e l o p e d to elicit multiple r e s p o n s e s o n f e e d i n g p r a c t i c e s that h a d b e e n u s e d o v e r t i m e , for the p u r p o s e of o b t a i n i n g d a t a o n t h e c h a n g e s in t h e f e e d i n g p r o c e s s a c c o r d i n g to infant a g e . A s u m m a r y of t h e q u e s t i o n n a i r e content is p r o v i d e d b e l o w a n d the c o m p l e t e tool is p r o v i d e d in Appendix E.  Infant Information: Birth d a t e , g e s t a t i o n a l a g e , g e n d e r , birth w e i g h t , birth length, sibling n u m b e r & a g e s  S i n g l e R e s p o n s e Format:  1. 2. 3. 4. 5. 6.  L i q u i d f e e d i n g p r a c t i c e s (6 q u e s t i o n s ) Infant/toddler c e r e a l f e e d i n g p r a c t i c e s (12 q u e s t i o n s ) O t h e r s o l i d f o o d s infant is eating (2 q u e s t i o n s ) M o t h e r ' s current infant/toddler c e r e a l p u r c h a s i n g p r a c t i c e s (7 q u e s t i o n s ) M o t h e r ' s p e r c e p t i o n of infant's a c c e p t a n c e of c o m m e r c i a l c e r e a l s (8 q u e s t i o n s ) Information r e c e i v e d or o b t a i n e d b y the m o t h e r a b o u t infant solid f o o d f e e d i n g a n d her p e r c e p t i o n s a b o u t t h e u s e f u l n e s s of t h e information (15 q u e s t i o n s )  S p r e a d s h e e t (multiple resp 1. 2. 3.  over time) Format:  T y p e s , b r a n d s a n d quantity of liquid infant r e c e i v e d o v e r time T y p e s , b r a n d s a n d quantity of c e r e a l infant r e c e i v e d o v e r time T y p e s , b r a n d s a n d quantity of other s o l i d f o o d s infant r e c e i v e d o v e r t i m e  34  DESIGN A N D M E T H O D S  3.3.3. Personal and Demographic Questionnaire T h e d e m o g r a p h i c q u e s t i o n n a i r e (19 q u e s t i o n s ) w a s a d a p t e d f r o m Innis et a l . ( 1 9 9 3 , 1994) a n d the S t a t i s t i c s C a n a d a 1 9 9 6 a n d 1991 C e n s u s . T h e q u e s t i o n n a i r e o b t a i n e d information o n t h e m o t h e r ' s a g e , marital s t a t u s , e d u c a t i o n , maternity l e a v e a n d t h e f a m i l y h o u s e h o l d s i z e , o c c u p a t i o n s , i n c o m e , l a n g u a g e s s p o k e n , e t h n i c b a c k g r o u n d , f o o d related p r a c t i c e s , d a y c a r e u s e , w h e r e the p a r e n t s h a d b e e n b o r n , a n d h o w long t h e y h a d lived in C a n a d a . T h e c o m p l e t e q u e s t i o n n a i r e is p r o v i d e d 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 i n t e r v i e w w a s r e c o r d e d in full o n t a p e . T h e t a p e w a s t h e n t r a n s c r i b e d v e r b a t i m . A l l t h e transcripts w e r e t h e n r e - c h e c k e d for a c c u r a c y b y t h e r e s e a r c h e r . T h e transcription t i m e v a r i e d b e t w e e n 8 a n d 16 h o u r s p e r t a p e . T r a n s c r i p t i o n t i m e w a s d e t e r m i n e d b y s e v e r a l f a c t o r s ; interview length, skill (that i n c r e a s e d with p r a c t i c e ) , r e c o r d i n g quality ( b a c k g r o u n d n o i s e ) , c o n v e r s a t i o n c h a r a c t e r i s t i c s (low t o n e s , q u i c k a n s w e r s ) , a n d t h e d e g r e e of n o n v e r b a l transcription (expressions).  3.4.2. Data Analysis  G r o u n d e d theory procedures are b a s e d on two analysis models: the concept-indicator m o d e l a n d 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 ( G l a z e r 1 9 7 8 ; S t r a u s s a n d C o r b i n , 1990). T h e c o n c e p t - i n d i c a t o r a n a l y s i s m o d e l d i r e c t s t h e c o n c e p t u a l c o d i n g of t h e identified line c o d e indicators a n d links t h e m with t h e e v o l v i n g c o n c e p t s . T h e c o n s t a n t c o m p a r i s o n of the m e a n i n g of indicators to e a c h o t h e r s l o w l y builds a c o n c e p t a n d its p r o p e r t i e s to b e l a b e l e d b y the a n a l y s t ( F i g u r e 3 p g . 2 7 ) . 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 directs the r e a s s e m b l i n g of the d a t a in n e w w a y s a n d is u s e d a s a f r a m e w o r k to s p e c i f y the c o n n e c t i o n s b e t w e e n the c a t e g o r i e s (Figure 4 p g . 28). 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 s o l i d f o o d f e e d i n g is illustrated in F i g u r e 15 in the  35  DESIGN AND METHODS results.  T h e s e 2 m o d e l s g u i d e d the d e v e l o p m e n t of 5 d a t a m a n a g e m e n t s p r e a d s h e e t s for the  d a t a a n a l y s i s p r o c e s s a n d c o n c u r r e n t d a t a m a n a g e m e n t p r o c e d u r e s . T h e s p r e a d s h e e t s a i d e d in the o r g a n i z a t i o n of a n d familiarization with t h e text, a n d then with the thinking, interpretation, u n d e r s t a n d i n g a n d integration of the e v o l v i n g c o n c e p t s a n d c a t e g o r i e s . T o a i d in t r a c k i n g d a t a throughout t h e a n a l y s i s p r o c e s s , line n u m b e r s w e r e u s e d o n e a c h p a g e of transcript (348 p a g e s ) for the identification of a n y c o d e d m a t e r i a l s o that it c o u l d b e t r a c e d b a c k to the original interview d a t a s o u r c e for verification. F i g u r e 5 illustrates the o r g a n i z a t i o n of the transcript d a t a . M a r g i n s p a c e w a s u s e d o n the right s i d e of e a c h p a g e of the transcript to h a n d write line c o d e s ( L C ) of important w o r d s a n d s e n t e n c e s (indicators) identified f r o m t h e text.  Interview Transcript with Line Codes in the right Margin Space  Interview n u m b e r (0001 ) a n d D a t e (7 m o n t h s , B r e a s t - f e e d i n g , Male, St. J a m e s Community Center)  Line C o d e s (indicators)  1 (line n u m b e r 1) 2 3 - starting at 4 m o n t h s w e g a v e 4- h i m rice c e r e a l but t h e n w h e n 5- h e didn't like that w e s w i t c h e d 6- to M i l u p a h e n e v e r liked P a b l u m  3- starting (a p r o c e s s ) 4- cereal type - rice 5- didn't like it (food rejection) 5- switching 6- cereal b r a n d s  1000...  v 2 0 0 0 (line n u m b e r 2 0 0 0 )  Figure 5. T r a n s c r i p t o r g a n i z a t i o n a n d line c o d i n g ( L C ) p r o c e d u r e s . P a r t i c i p a n t n u m b e r s a n d d e s c r i p t i v e d a t a (e.g., infant a g e a n d g e n d e r , milk f e e d i n g m e t h o d , recruitment site) w e r e written at t h e top of the p a g e . P a g e line n u m b e r s w e r e i n s e r t e d o n e a c h p a g e to track d a t a t h r o u g h o u t the a n a l y s i s p r o c e s s . T r a n s c r i p t i o n text w a s t y p e d o n half of the p a g e . M a r g i n s p a c e o n the right s i d e of the p a g e w a s u s e d to efficiently t r a n s f e r indicator line c o d e s f r o m t h e text to the m a r g i n s p a c e , for a n a l y s i s .  36  DESIGN AND METHODS T h e resulting line codes, as illustrated above, were transferred to an indicator index summary spreadsheet (MSS) (Figure 6). T h e s e spreadsheets were used as a quick reference of all line codes with the identifying line number from the original data source. T h e 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. T h e 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. T h e MSS spreadsheet aided in efficiently analyzing the large amount of data from the transcripts, systematically, both within and across the interviews.  37  DESIGN A N D M E T H O D S  Indicator Index S u m m a r y S p r e a d s h e e t (IISS)  Interview 0001 0002 3- starting (a process) 4-cereal type - rice 5-didn't like i (food rejectic n) 5- switching 6-cereal bran ds  0003  0004  0005  0006  Indicator Index S u m m a r y S p r e a d s h e e t (IISS)  Interview 0007  0008  0009  0010  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) f o r line c o d e o r g a n i z a t i o n . T h e line c o d e s f r o m e a c h interview w e r e t r a n s f e r r e d into 2 , 6 c o l u m n indicator i n d e x 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 h e a d i n g of e a c h c o l u m n . T h e original line n u m b e r w a s a l s o t r a n s f e r r e d to track the original s o u r c e of the d a t a t h r o u g h o u t t h e a n a l y s i s p r o c e s s . C o n s t a n t c o m p a r a t i v e a n a l y s i s within a n d a c r o s s c a s e s w a s started u s i n g t h e open coding procedures.  A reflexive j o u r n a l w a s kept to d o c u m e n t e v o l v i n g c o n c e p t s , c a t e g o r i e s a n d their r e l a t i o n s h i p s . T h i s journal b e c a m e the a v e n u e for e v o l v i n g t h e o r e t i c a l thinking a b o u t the d a t a , i n c l u d i n g c r o s s c o m p a r i s o n s a n d p r e l i m i n a r y interpretations.  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 w e r e u s e d to r e c o r d t h e a n a l y s t ' s thinking a n d w e r e l a b e l e d m e m o s p r e a d s h e e t a a n d b ( M S a n d M S ) , r e s p e c t i v e l y . A n e x a m p l e of the first m e m o s p r e a d s h e e t is p r o v i d e d in a  b  F i g u r e 7. T h e s e c o n d m e m o s p r e a d s h e e t ( M S ) is d e s c r i b e d in m o r e detail in F i g u r e 9. b  38  DESIGN A N D M E T H O D S  Memo Spreadsheet (MS )  Diagram Example,  a  Concept/ Analysis Category (e.g. starting) Session Dates  Starting.... A d i a l o g u e of what, when, who, why, a n d h o w m o t h e r s start solid f o o d s a n d the interpretations of w h a t t h e f e e d i n g p r o c e s s is like for t h e s e m o t h e r s .  Figure 7. T h e m e m o s p r e a d s h e e t ( M S ) w a s u s e d for t h e o r g a n i z a t i o n of a n a l y s t ' s theoretical thinking d u r i n g t h e o p e n c o d i n g a n a l y s i s p r o c e d u r e s . a  T h e c o n c e p t o r c a t e g o r y w a s p l a c e d a s a h e a d i n g a l o n g with t h e d a t e of t h e a n a l y s i s s e s s i o n . R e f l e c t i v e thinking o n t h e m e a n i n g s of t h e d a t a w a s written a n d s u c c e s s i v e r e v i s i o n s w e r e d o c u m e n t e d a s the a n a l y s i s c o n t i n u e d . G e n e r a t i v e q u e s t i o n s ( w h e n , w h y , w h a t , w h o , a n d h o w s o m e b e h a v i o r h a p p e n e d ) w e r e a s k e d of the d a t a to p r o v i d e a f r a m e w o r k to write f r o m . D i a g r a m s a n d f i g u r e s w e r e i n c l u d e d i n t h e j o u r n a l to a i d in integrative thinking a b o u t r e l a t i o n s h i p s of c o n c e p t s o r c a t e g o r i e s to e a c h other, a n d to a i d in m a k i n g explicit, u n c o n s c i o u s p e r s o n a l b i a s e s that m a y i n f l u e n c e t h e a n a l y s i s . T h e journal entry r e v i s i o n s reflected i n c r e a s i n g l y s o p h i s t i c a t e d r e c o n s t r u c t i o n s of t h e p r e v i o u s v e r s i o n s .  T h e m a j o r c o n c e p t s a n d c a t e g o r i e s that e v o l v e d in t h e o p e n c o d i n g p r o c e d u r e w e r e u s e d a s t h e g u i d i n g f r a m e w o r k t o g a t h e r s u b s e q u e n t d a t a s y s t e m a t i c a l l y f r o m a c r o s s t h e i n t e r v i e w s . In o r d e r to m a n a g e this d a t a , a third s p r e a d s h e e t , t h e 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 , w a s d e v e l o p e d ( F i g u r e 8). A l l of t h e d a t a f r o m within a n d a c r o s s t h e interviews that c o u l d potentially 'fit' into a s p e c i f i c c o n c e p t / c a t e g o r y w e r e t r a n s f e r r e d to t h e 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 ) with t h e identifying line n u m b e r f r o m t h e o r i g i n a l transcript. T h e n , t h e original q u o t e within its fuller c o n t e x t w a s t r a n s f e r r e d , a g a i n i n c l u d i n g t h e identifying line n u m b e r , to this s u m m a r y s p r e a d s h e e t . B e c a u s e a n a l y s i s quality c o u l d v a r y f r o m interview to interview  39  DESIGN A N D M E T H O D S 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  0012 -all the potential data (including source) from interview number 12 on the concept mixing.  0  0  6  Figure 8. The 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 ) 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 A N D M E T H O D S A s w o u l d b e e x p e c t e d , t h e interpretations r e c o r d e d in the reflexive journal e v o l v e d d u r i n g the a n a l y s i s p r o c e s s . T h e first a n a l y t i c m e m o s ( M S ) f o c u s e d o n articulating interpretations f r o m a  the o p e n c o d i n g a n a l y s i s p r o c e d u r e s . A s the a n a l y s i s c o n t i n u e d a n d p r o g r e s s e d to the a x i a l c o d i n g p r o c e d u r e s the m e m o s p r e a d s h e e t n o w reflected the i n c l u s i o n of the c o n d i t i o n s within a s p e c i f i c c o n t e x t a n d the c o n s e q u e n c e s of a c t i o n s a n d interactions 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 s p r e a d s h e e t ( M S ) w a s d e s i g n e d to c a p t u r e the interpretations f r o m the axial b  c o d i n g p r o c e d u r e s ( F i g u r e 9).  Memo Spreadsheet (MSb) Concept/Category;  Interview # W h e n  Starting  What  Why  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 ) w a s u s e d for the o r g a n i z a t i o n of a n a l y s t ' s t h e o r e t i c a l thinking d u r i n g the a x i a l c o d i n g a n a l y s i s p r o c e d u r e s . T h e c o n c e p t o r c a t e g o r y w a s p l a c e d a s a h e a d i n g , illustrated in this figure is 'starting', a n d the interview n u m b e r w a s p l a c e d o n the left c o l u m n . D a t a d e r i v e d f r o m the g e n e r a t i v e q u e s t i o n s (e.g., w h e n , w h y , w h a t , w h o , a n d h o w s o m e b e h a v i o r h a p p e n e d ) w e r e s y s t e m a t i c a l l y s o r t e d into this f r a m e w o r k . P l a u s i b l e r e l a t i o n s h i p s b e t w e e n c o n c e p t s or c a t e g o r i e s w e r e identified a n d d o c u m e n t e d a c r o s s all of the i n t e r v i e w s . T h e journal e n t r i e s w e r e r e v i s e d n u m e r o u s t i m e s a n d reflect i m p r o v e m e n t s in the a n a l y s t ' s interpretations. b  41  DESIGN AND METHODS Additional integrative d a t a d i s p l a y s w e r e d e v e l o p e d to illustrate the a n a l y s i s of the c o n c e p t / c a t e g o r y s u m m a r y s h e e t d a t a a c c o r d i n g to 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 ( G l a z e r 1 9 7 8 ; S t r a u s s & C o r b i n , 1990) a n d the r e s e a r c h e r ' s interpretations.  T h e integrative d a t a d i s p l a y s a l s o  e v o l v e d to reflect a m o r e s o p h i s t i c a t e d u n d e r s t a n d i n g of the m o t h e r s ' solid f o o d f e e d i n g p r a c t i c e s . T h e a x i a l c o d i n g p r o c e d u r e s w e r e u s e d to d i s c o v e r ' p r o c e s s ' from the d a t a . T h e s e results a r e illustrated in F i g u r e 15 of the c a u s a l - c o n s e q u e n c e m o d e l ( a d a p t e d f r o m G l a s e r , 1 9 7 8 ) . T h e p r o p o s e d s t a t e m e n t s of p l a u s i b l e relationship ( h y p o t h e s e s ) b e t w e e n the m o t h e r ' s f e e d i n g p r a c t i c e s a n d t h e infant's c e r e a l c o n s u m p t i o n patterns e v o l v e d , in part, f r o m the sorting of the infant's s o l i d f o o d transition g r a p h s into low, m e d i u m a n d h i g h c e r e a l c o n s u m p t i o n g r o u p s .  3.5.  Questionnaire Analysis T h e infant f e e d i n g p r a c t i c e q u e s t i o n n a i r e w a s c o m p l e t e d with 9 of the 12 m o t h e r s w h o  p a r t i c i p a t e d in the s t u d y . T h e q u e s t i o n n a i r e d a t a w e r e u s e d to c o m p l e m e n t the interview d a t a . D a t a f r o m the q u e s t i o n n a i r e s w a s not u s e d to statistically quantify r e s p o n s e s b e c a u s e t h e s a m p l e w a s too s m a l l , a n d this w a s not the i n t e n d e d p u r p o s e . T h e q u e s t i o n n a i r e d a t a w e r e u s e d to c o m p l e m e n t portions of interview d a t a , s u c h a s in the c a s e of the transition g r a p h s ( c h e c k i n g r e s p o n s e s to interview d a t a ) . T h e q u e s t i o n n a i r e d a t a a i d e d in u n d e r s t a n d i n g t h e different r e s p o n s e s a n d t y p e s of d a t a that c a n b e o b t a i n e d f r o m u s i n g t h e 3 different f o r m a t s ( c l o s e r e s p o n s e q u e s t i o n s at o n e point in t i m e , s p r e a d s h e e t r e s p o n s e s o v e r t i m e , a n d interview r e s p o n s e s ) . T h e p e r s o n a l a n d d e m o g r a p h i c q u e s t i o n n a i r e w a s u s e d to p r o v i d e d e m o g r a p h i c d a t a o n t h e c h a r a c t e r i s t i c s of the s t u d y participant.  42  RESULTS  Chapter IV  4.1.  Participant characteristics  A total of 12 w o m e n p a r t i c i p a t e d in this s t u d y . O f the 12 w o m e n , 7 h a d infants w h o w e r e b e t w e e n 6.5 a n d 7.5 m o n t h s of a g e , 3 h a d infants w h o w e r e b e t w e e n 8 a n d 9 m o n t h s a n d 2 h a d infants w h o w e r e 9 m o n t h s of a g e ( T a b l e 1). T w o thirds (9/12) of the infants w e r e m a l e . Half of the w o m e n h a d a g r o s s f a m i l y i n c o m e g r e a t e r t h a n $ 7 0 , 0 0 0 a n d 2 w o m e n h a d a n a n n u a l f a m i l y i n c o m e l e s s t h a n $ 2 0 , 0 0 0 . O f t h e 12 w o m e n , o n l y o n e w o m a n h a d two c h i l d r e n . M o s t of the w o m e n w e r e m a r r i e d or living with a partner, 2 w e r e s i n g l e . A l l of the m o t h e r s a n d all but 1 father h a d c o m p l e t e d p o s t - s e c o n d a r y e d u c a t i o n . T w o thirds of the m o t h e r s a n d t h r e e q u a r t e r s of the fathers h a d c o m p l e t e d U n i v e r s i t y . T h e majority of m o t h e r s (9/12) w e r e b e t w e e n 2 5 a n d 3 4 y e a r s of a g e . L e s s t h a n half of t h e m o t h e r s u s e d d a y c a r e . O f t h o s e w h o u s e d d a y c a r e , 3 u s e d it part t i m e a n d 2 full t i m e .  43  RESULTS  Table 1 Participant Characteristics  Number  Infant age (months) 6.5 - 7.5 >8-<9 9  7 3 2  Infant Gender  male female Gross Family Income (x $1000)  9 3 1 1 1 2 1 6  <10  10-19 20-29 30-50 50-59 >70 Birth Order  first second  11 1  Marital Status  Single Married/common-law  2 10  Mother's education  College University  4 8  Father's education  High School College University  1 2 9  Mother's age (yrs)  20-24 25-29 30-34 35+  2 5 4 1  Alternate Infant Care  Part time (1-2 d/wk) Full time (5d/wk 8hrs/d)  3 2  A total of 12 mothers participated.  44  1  RESULTS  4.2.  Overview  T h e interview d a t a w e r e a n a l y z e d u s i n g g r o u n d e d - t h e o r y p r o c e d u r e s to d e s c r i b e the m o t h e r s ' s o l i d f o o d f e e d i n g p r o c e s s e s a n d to e x p l o r e the p l a u s i b l e relationship b e t w e e n infant s o l i d f o o d f e e d i n g p r a c t i c e s a n d infant nutrition.  D u r i n g t h e c o n s t a n t c o m p a r a t i v e a n a l y s i s , five  t h e m e s w e r e d i s c o v e r e d . T h e 5 t h e m e s - the feeding ways of feeding,  gaining  expertise  a n d tailoring  following s e c t i o n s . T h e last t h e m e - tailoring  process,  the transition  the transition  perceiving  process  process  infant food  needs,  a r e d e s c r i b e d in t h e w a s identified a s the c o r e  t h e m e b e c a u s e it a c c o u n t s for the m o s t variation in t h e m o t h e r s ' b e h a v i o r s within the c o n t e x t of t h e s o l i d f o o d f e e d i n g p r o c e s s . T h e 5 t h e m e s a r e illustrated in t h e following 3 - d i m e n s i o n a l m o d e l ( F i g . 10).  T h e m o d e l p r o v i d e s a v i s u a l p r e s e n t a t i o n of t h e f i n d i n g s . T h i s c o n c e p t u a l m o d e l a i d s  in refining p l a u s i b l e r e l a t i o n s h i p s a m o n g t h e t h e m e s a n d e n h a n c e s u n d e r s t a n d i n g of the n u m e r o u s c o n d i t i o n s that potentially i n f l u e n c e t h e s o l i d f o o d f e e d i n g p r o c e s s . T h e a v a i l a b l e d a t a c l e a r l y s u g g e s t that the 'way" that t h e m o t h e r 'tailors' h e r f e e d i n g strategy during the transition p r o c e s s c o u l d i m p a c t o n t h e infant's a c c e p t a n c e of s o l i d f o o d s a n d t h u s , potentially, t h e infant's solid food consumption patterns.  45  RESULTS  Ways of feeding Dynamic  Perceiving Infant Food Needs  . switching . mixing . adjusting . engagi"9 etc.  Food preferences (taste-texture)  Hunger  Static  . epeatediy ottering disliked toods . waiting . distracting etc. ' r  Readiness . | Developmental y < f  1 /  /  /  /  F i g u r e 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  f  RESULTS  4.3.  The feeding process  T h e first t h e m e - the feeding process, of t h e 3 - d i m e n s i o n a l infant s o l i d f o o d f e e d i n g m o d e l is illustrated in F i g u r e 1 1 . T h e first t h e m e is c o m p r i s e d of 4 m a j o r c o n c e p t s - starting t h e f e e d i n g p r o c e s s , t h e infant's a c c e p t a n c e o r rejection r e s p o n s e , t h e infant's a g e a n d t h e s o l i d f o o d o f f e r e d . T h e m o d e l e m p h a s i z e s t h e c o n n e c t i o n b e t w e e n t h e m o t h e r - infant pair a n d f o o d a s t h e integral part of the d y n a m i c (interactional) f e e d i n g p r o c e s s . T h e m o t h e r s in this s t u d y d e s c r i b e d their e x p e r i e n c e s f e e d i n g their infants a s t h e y p r o g r e s s e d f r o m t h e e x c l u s i v e liquid diet to t h e c o m b i n e d liquid a n d s o l i d f o o d 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 t h e 3 - d i m e n s i o n a l infant s o l i d f o o d f e e d i n g m o d e l is the feeding process. T h e first t h e m e i n c l u d e s 3 c o n c e p t s (food a c c e p t a n c e / r e j e c t i o n , starting t h e f e e d i n g p r o c e s s a n d infant a g e ) .  47  RESULTS T h e m o t h e r s d e s c r i b e d 'starting' t h e f e e d i n g p r o c e s s a n d 'offering' their infants s o l i d f o o d s . In turn, the infants either a c c e p t e d o r r e j e c t e d w h a t w a s o f f e r e d . T h e p r o c e s s a p p e a r e d to b e c i r c u l a r in nature a n d t h u s , is highlighted b y t h e 2 a r r o w s in t h e m o d e l . T h e s e a r r o w s indicate different b e h a v i o r a l p a t h w a y s , d e p e n d i n g o n h o w t h e infant r e s p o n d e d to the s o l i d food(s) b e i n g offered.  T h e s u b s e q u e n t t h e m e s in t h e s t u d y that build t h e c o n c e p t u a l m o d e l are related to the  context - the feeding  process  - a s either c o n d i t i o n s , a c t i o n / i n t e r a c t i o n a l s t r a t e g i e s , or  c o n s e q u e n c e s . T h e m o t h e r s d e s c r i b e d their e x p e r i e n c e s of 'starting' the f e e d i n g p r o c e s s a n d the f a c t o r s that i n f l u e n c e d their f e e d i n g d e c i s i o n s .  4.3.1 Starting the feeding process T h r e e m o t h e r s first i n t r o d u c e d infant c e r e a l s at 3 m o n t h s , six m o t h e r s i n t r o d u c e d c e r e a l s b e t w e e n 4 a n d 5 m o n t h s a n d t h r e e m o t h e r s b e t w e e n 5 a n d 5 Vfe m o n t h s . M o s t of the m o t h e r s (9/12) i n t r o d u c e d s o l i d f o o d to their infant within the r e c o m m e n d e d a g e r a n g e of 4 to 6 m o n t h s . Interestingly, the m o t h e r s d e s c r i b e d the m e a n i n g of 'starting t h e f e e d i n g p r o c e s s ' , h o w e v e r , t h e a g e of s o l i d f o o d introduction p r o v i d e d o n l y a v a g u e d e s c r i p t i o n of 'starting'. T h e following m o t h e r s d e s c r i b e d distinct 'starting' patterns in their f e e d i n g that t h e y articulated a s " s p o r a d i c " v e r s u s "routine" f e e d i n g . T h e a g e t h e s e m o t h e r s started s o l i d f o o d f e e d i n g w a s d e s c r i b e d not a s the initial a g e of 'introduction', but rather a s the a g e w h e n t h e y w e r e a c t u a l l y f e e d i n g s o l i d f o o d o n a regular b a s i s o r 'routinely*.  Initial f e e d i n g a t t e m p t s w e r e not c o n s i d e r e d a s 'really starting'  s o l i d s . T h e following q u o t e s illustrate the m o t h e r ' s c o n c e p t u a l i z a t i o n of initial f e e d i n g a t t e m p t s a s b e i n g ' s p o r a d i c ' a n d t h e n t h e s u b s e q u e n t 'routine' f e e d i n g of s o l i d s o n a regular b a s i s .  "We, I think we tried as early as 3 months... to sleep at night] and then we stopped. difference  and it was just more hassle  a bit older, like after four months until 6 months...  2  Because  we tried [cerealf  we realized  a couple  nights [to get  that it wasn't really making  than it was worth. I think we tried it. ..sporadically  between  4 and 6 months  but nothing really on a regular  (7-147)" . 3  Parentheses indicate added context to increase reading ease and understanding. 48  him  a as he got basis  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 A> 1  months. And then I started with the cereals first ... (10-87)". 4  'Starting t h e f e e d i n g p r o c e s s ' w a s d e s c r i b e d b y the following mother, a g a i n not a s the a g e w h e n f o o d s w e r e initially i n t r o d u c e d , but a s the a g e of 'routine' s o l i d f o o d f e e d i n g . D u r i n g t h e following m o t h e r ' s initial f e e d i n g a t t e m p t s s h e d e s c r i b e d both t h e irregular start - s t o p nature of ' f e e d i n g ' s o l i d s , in relation to h e r p e r c e p t i o n s of h e r infant's f o o d n e e d s (i.e., infant h u n g e r ) . T h e f o l l o w i n g q u o t e a l s o illustrates t h e c o n c e p t of 'starting' in s e v e r a l distinct w a y s . F o r e x a m p l e , this m o t h e r a p p e a r s to b e starting ' s p o r a d i c ' initial f e e d i n g , starting 'routine' f e e d i n g a n d 'starting the f e e d i n g p r o c e s s ' . Starting t h e f e e d i n g p r o c e s s , in this m o t h e r ' s c a s e , a l s o s e e m s to i n c l u d e the m o t h e r ' s p r o g r e s s i o n to f e e d i n g i n c r e a s i n g v a r i e t i e s of s o l i d f o o d s , s u c h a s f r o m c e r e a l s to v e g e t a b l e s , a s w e l l a s f o o d c o l o r variety, s u c h a s within the v e g e t a b l e f o o d g r o u p . T h i s q u o t e highlights t h e t i m e it t o o k b e t w e e n t h e initial introduction of s o l i d f o o d s to f e e d i n g s o l i d s o n a r e g u l a r b a s i s ('routinely'). W i t h r e s p e c t to iron nutrition, it is of interest that the m o t h e r s in this s t u d y took f r o m 2 w e e k s to o v e r 3 m o n t h s after t h e initial s o l i d f o o d 'introduction' attempts to start f e e d i n g iron fortified infant c e r e a l s o n a r e g u l a r b a s 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 m o t h e r s in this s t u d y , a s the q u o t e s illustrate, d e s c r i b e t h e infant's a g e a n d the t y p e of s o l i d f o o d t h e y offered a s important f a c t o r s within the context of t h e f e e d i n g 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). ... indicates either pauses in the mother's conversation or the joining of different quotes on the same topic.  4  49  RESULTS T h e r e f o r e , t h e s e 2 c o n c e p t s in t h e " f e e d i n g p r o c e s s " t h e m e a r e illustrated in t h e c o n c e p t u a l m o d e l a s intertwined with 2 o t h e r c o n c e p t s : 'starting/offering' a n d ' a c c e p t a n c e / r e j e c t i o n ' of s o l i d food(s). T h e p r e v i o u s , a s w e l l a s t h e f o l l o w i n g q u o t e s , highlight t h e relationship b e t w e e n t h e infant's a g e , t h e s o l i d f o o d offered a n d t h e m o t h e r ' s a c t i o n s - 'starting' t h e f e e d i n g p r o c e s s .  4.3.2.  Reasons for starting solid food In g e n e r a l , t h e m o t h e r s in this s t u d y s t a t e d that t h e y h a d 'started' s o l i d f o o d at t h e a g e  t h e y s p e c i f i e d f o r o n e o r m o r e of three m a i n r e a s o n s . T h e y u s u a l l y d e s c r i b e d a c o m b i n a t i o n of r e a s o n s a s important in i n f l u e n c i n g their f e e d i n g p r a c t i c e s . T h e three m a i n r e a s o n s identified f r o m t h e d a t a w e r e a d v i c e (from r e a d i n g o r v e r b a l l y ) , p e r c e i v e d infant f o o d n e e d s , a n d w a n t i n g the infant to s l e e p t h r o u g h t h e night. T h e majority of m o t h e r s (10/12) s t a t e d that t h e y h a d started first f o o d s at t h e a g e t h e y s p e c i f i e d b e c a u s e of t h e a d v i c e t h e y h a d o b t a i n e d either f r o m r e a d i n g o r verbally. T h e majority of a d v i c e o b t a i n e d b y m o t h e r s a p p e a r e d to b e s p e c i f i c to t h e a g e of introduction of s o l i d f o o d s .  "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 (2174)".  M a n y m o t h e r s (7/12) a l s o s t a r t e d f e e d i n g s o l i d f o o d s b e c a u s e of their p e r c e p t i o n s that the infant b e h a v i o r s that t h e y o b s e r v e d m e a n t their infant w a s ' r e a d y for, o r their infant ' w a n t e d ' 1  s o l i d f o o d . A s illustrated in t h e f o l l o w i n g q u o t e , t h e infant's s i g n s of ' r e a d i n e s s ' a p p e a r e d to influence the mother's s u b s e q u e n t solid food feeding d e c i s i o n s . W h e n the mothers o b s e r v e d infant ' s i g n s ' that t h e y p e r c e i v e d a s t h e infant ' w a n t i n g ' s o l i d f o o d t h e y r e s p o n d e d b y starting t h e feeding process.  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)".  D e v e l o p m e n t a l b e h a v i o r s (i.e., infant b e i n g 'interested') a n d p h y s i c a l c u e s (i.e., infant sitting) a p p e a r to b e 'trigger' b e h a v i o r s that i n f l u e n c e d m o t h e r s to start s o l i d f o o d s . M o t h e r s ' p e r c e p t i o n of infant ' r e a d i n e s s ' is d e s c r i b e d in m o r e detail in t h e next s e c t i o n o n ' p e r c e i v i n g infant f o o d n e e d s ' . T h e c o n c e p t 'fits' into both s e c t i o n s s i n c e , in this s e c t i o n , t h e m o t h e r ' s p e r c e p t i o n of h e r infant's ' r e a d i n e s s ' a p p e a r e d to i n f l u e n c e t h e a g e that s o l i d f o o d s w e r e i n t r o d u c e d a n d in t h e next s e c t i o n , the m o t h e r s a p p e a r e d to p e r c e i v e that the infant's ' r e a d i n e s s ' i n f l u e n c e d their a c c e p t a n c e of s o l i d f o o d s . C o n s e q u e n t l y , t h e s e p e r c e p t i o n s a p p e a r e d to i n f l u e n c e the m o t h e r ' s f e e d i n g d e c i s i o n s initially, w h e n 'starting' t h e f e e d i n g p r o c e s s , a s w e l l a s at later s t a g e s of the feeding process. O n e q u a r t e r of the m o t h e r s (4/12) s t a t e d that they h a d i n t r o d u c e d s o l i d f o o d s at the a g e t h e y d i d b e c a u s e their infant w a s not s l e e p i n g t h r o u g h the night. E x t e r n a l f a c t o r s , s p e c i f i c a l l y a d v i c e f r o m f a m i l y a n d p e e r s s e e m e d to b e v e r y influential to t h e s e m o t h e r s ' f e e d i n g d e c i s i o n s . A s t h e f o l l o w i n g q u o t e s illustrate, t h e infant w a k i n g in the night a p p e a r s to h a v e b e e n p e r c e i v e d by t h e s e m o t h e r s a s a h u n g e r c u e a n d a ' s i g n ' of r e a d i n e s s to start s o l i d s . It is of interest that m o s t (3/4) of the m o t h e r s w h o s t a r t e d s o l i d s b e c a u s e their infant w a s w a k i n g in t h e night a l s o s t a t e d that starting s o l i d s w a s not s u c c e s s f u l in h e l p i n g their infant s u b s e q u e n t l y s l e e p t h r o u g h the night. T h e c o n n e c t i o n b e t w e e n t h e m o t h e r s ' p e r c e p t i o n s c o n c e r n i n g d a y t i m e s o l i d f o o d f e e d i n g a n d uninterrupted night t i m e s l e e p h o u r s is c l e a r l y important b e c a u s e t h e s e p e r c e p t i o n s a p p e a r e d to s t r o n g l y i n f l u e n c e s o l i d f o o d f e e d i n g d e c i s i o n s (i.e., 'too' e a r l y 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  RESULTS months...  (7-77).  [The]  doctor  told us not to and we did it anyway  law said "it really does work", "everybody  in the family has done if.  make him sleep any more and he didn't seem spitting it out  (7-98)...Because  my mothe --in-  So we tried it and it didn'  to really take to it because  he was still kind of  (7-100)".  Multiple e x t e r n a l f a c t o r s , s u c h a s a d v i c e , c o m p a r i n g with o t h e r m o t h e r s , rapid infant g r o w t h , b r e a s t - f e e d i n g f r e q u e n c y a n d s l e e p i n g t h r o u g h t h e night, a p p e a r e d to i n f l u e n c e w h e r t h e following m o t h e r s t a r t e d f e e d i n g s o l i d f o o d s . T h e q u o t e a l s o highlights the c o m p l e x i t y of facti <rs that i n f l u e n c e d this m o t h e r ' s s o l i d f o o d f e e d i n g d e c i s i o n s . Interestingly, a l t h o u g h this m o t h e r o b s e r v e d that h e r infant w a s g r o w i n g v e r y w e l l o n b r e a s t milk s h e c h o s e to introduce s o l i d fo< d s at 3 m o n t h s ('too early"). T h e infant's positive g r o w t h r e s p o n s e to t h e milk f e e d i n g m e t h o d di< I not a p p e a r to i n f l u e n c e h e r f e e d i n g d e c i s i o n s a s m u c h a s the other e x t e r n a l f a c t o r s , s u c h a s h e r m o t h e r ' s a d v i c e a n d c o m p a r i n g f e e d i n g p r a c t i c e s with other m o t h e r s at w o r k .  "At three months night before  so fast he I started him on a regular  every two to three hours he was only seven  lot of weight very quickly. the Pablum...so completely  idea. Because  twenty pounds  pounds  Because  twelve ounces  Pablu n at health  we were brea st  when he was bon >.  by the time he was four months.  So he put o\ i a  Ya and he didn't [sleep through the night]. But he really seemed  I just kept doing it. He didn't start sleeping  weaned...at  she was a public  and that is what they did back then (8-34)"....  But he was I think twenty almost  sleeping.  he was growing  he went to bed... which was my mother's  nurse back in the sixties feeding  because  about 6-6 ¥2 months  Part of the reason  I started Pablum  (8-311).  through  Friends  to  the night until I had  him  at work said... Their baby  was  so early... I thought... [He's] got to be sleeping  ike  0 I-  665)".  4.3.3. Reasons for solid food selection. T h e first s o l i d f o o d that m o s t m o t h e r s i n t r o d u c e d (11/12) w a s c o m m e r c i a l iron-fortifie< I infant rice c e r e a l . T h e o n l y m o t h e r w h o didn't i n t r o d u c e rice c e r e a l first i n t r o d u c e d m i x e d c e n sals i n s t e a d b e c a u s e of a p u r c h a s i n g error. T h e m o t h e r s in this s t u d y a p p e a r e d to follow the c u m snt infant f e e d i n g r e c o m m e n d a t i o n s , w i t h r e g a r d s to t h e t y p e of s o l i d f o o d t h e y offered their infan s first. T h e two m o s t c o m m o n r e a s o n s the m o t h e r s in this s t u d y s t a t e d for s e l e c t i n g the s o l i d fc o d s  52  RESULTS that t h e y did w a s infant s o l i d f o o d a c c e p t a n c e (12/12) a n d rejection (6/12) a n d c o n c e r n a b o u t a l l e r g i e s (8/12). T h e infant's a c c e p t a n c e of the s o l i d f o o d s offered c l e a r l y i n f l u e n c e d the m o t h e r ' s s o l i d f o o d s e l e c t i o n c h o i c e s . F u r t h e r , half of the m o t h e r s ' f o o d s e l e c t i o n d e c i s i o n s w e r e s p e c i f i c a l l y d e t e r m i n e d b y t h e infants' rejection of the s o l i d f o o d offered. T h e a r r o w s in the m o d e l highlight the c i r c u l a r relationship b e t w e e n t h e m o t h e r - infant pair a n d s o l i d f o o d . T h e a r r o w s in the m o d e l s y m b o l i z e t h e m o t h e r starting t h e s o l i d f o o d f e e d i n g p r o c e s s , t h e infant r e s p o n d i n g to what w a s o f f e r e d , the m o t h e r t h e n r e s p o n d i n g to h e r infant's f o o d c u e s a n d s o o n - the circular p r o c e s s . T h e q u o t e s b e l o w highlight t h e infant's rejection r e s p o n s e to t h e s o l i d f o o d that w a s f e d . A g a i n , the m o t h e r s a p p e a r to b e a d a p t i n g 'what' t h e y f e d their infants in r e s p o n s e to the infant's s o l i d f o o d a c c e p t a n c e or rejection r e s p o n s e . F o r e x a m p l e , t h e y either c o n t i n u e d to f e e d w h a t w a s a c c e p t e d , s w i t c h e d f o o d s o r b r a n d s , o r m i x e d f o o d s together to p r o m o t e a c c e p t a n c e . T h e f e e d i n g s t r a t e g i e s that t h e m o t h e r s u s e d to g a i n s o l i d f o o d a c c e p t a n c e a r e further d e v e l o p e d later in t h e third t h e m e - w a y s of f e e d i n g . Interestingly, the transcripts s u g g e s t that both the m o t h e r a n d t h e infant i n f l u e n c e d the p r o g r e s s i o n of s o l i d f o o d a c c e p t a n c e (i.e., the s o l i d f o o d f e e d i n g process).  "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 C o n s i s t e n t with information p r o v i d e d in the p u b l i c health g u i d e l i n e s , m o s t of t h e s e m o t h e r s (8/12) a l s o e x p r e s s e d a n a w a r e n e s s of a n d / o r c o n c e r n a b o u t a l l e r g i e s a s a m a j o r r e a s o n for introducing t h e first f o o d s that t h e y d i d . T h u s , t h e information f r o m the g u i d e l i n e s a p p e a r s to h a v e influenced the mothers' solid food selection d e c i s i o n s a n d s u b s e q u e n t solid food feeding p r a c t i c e s . T h e following q u o t e e m p h a s i z e s , in g e n e r a l , h o w s t r o n g l y m o t h e r s a d h e r e to t h e f e e d i n g g u i d e l i n e s with r e s p e c t to a l l e r g y a w a r e n e s s , f o o d s e l e c t i o n a n d a l l e r g y p r e v e n t i o n . M a n y c o m m o n p h r a s e s that m o t h e r s u s e d that reflect g u i d e l i n e ' a d h e r e n c e ' include, " w e w e n t with the list...that t h e y r e c o m m e n d starting with t h e least a l l e r g e n i c . . . l i k e what w e ' r e told a n d t h e n w e n t o n to..." a n d " d u r i n g this time I w a s testing for a l l e r g i e s " . T h e interview d a t a c l e a r l y s u g g e s t that m o t h e r s follow g u i d e l i n e s for direction r e g a r d i n g the a g e to introduce s p e c i f i c solid f o o d s a n d for t h e p r o g r e s s i o n of i n c r e a s i n g t h e variety of s o l i d f o o d s in the diet, but t h e y a p p e a r to b e following the g u i d e l i n e s with a f o c u s , in particular, o n a l l e r g y p r e v e n t i o n .  "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 m o t h e r s w e r e c o n c e r n e d a b o u t t h e p o s s i b i l i t y of their infant h a v i n g a f o o d allergy. T h i s c o n c e r n a p p e a r s to b e a m a j o r d e t e r m i n a n t of not o n l y w h a t f o o d s w e r e f e d first, but a l s o h o w s o l i d f o o d s w e r e f e d , with r e s p e c t to i n c r e a s i n g variety, i n c r e a s i n g quantity, a n d the transition p a c e . T h e following two q u o t e s d e s c r i b e h o w t h e m o t h e r ' s p e r c e p t i o n of 'testing for a l l e r g i e s ' could impact on how quickly solid foods are introduced. "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  RESULTS T h e following q u o t e a l s o highlights the m o t h e r ' s c o n c e r n a b o u t t h e possibility of h e r infant h a v i n g a f o o d a l l e r g y a n d the i m p a c t that this c o n c e r n h a d o n w h e n s h e ' r o u t i n e l y started s o l i d f o o d s (i.e., at 6 m o n t h s ) . T h e q u o t e illustrates potential c o n f u s i o n a b o u t f o o d a n d a l l e r g i e s , s i n c e this m o t h e r h a d started ' s p o r a d i c ' s o l i d f o o d f e e d i n g b y 3 m o n t h s of a g e , in o r d e r to get h e r infant to s l e e p t h r o u g h t h e night (quote not i n c l u d e d ) . T h e c o n c e p t starting 'routine' f e e d i n g v e r s u s ' s p o r a d i c ' introduction is important h e r e s i n c e the m o t h e r ' s e a r l y s o l i d f o o d introduction a p p e a r e d to b e p e r c e i v e d b y h e r a s not putting h e r infant at risk for f o o d a l l e r g i e s . A l t h o u g h the m o t h e r c l e a r l y articulated that h e r f e e d i n g p r a c t i c e s w e r e f o c u s e d a r o u n d a l l e r g y p r e v e n t i o n a n d a p p e a r e d to follow the g u i d e l i n e s with r e s p e c t to the t y p e of f o o d s s h e s e l e c t e d , s h e did not a p p e a r to follow the infant f e e d i n g g u i d e l i n e s , with r e s p e c t to t h e 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 h e m e - t h e f e e d i n g p r o c e s s d e s c r i b e s t h e c o n t e x t s u r r o u n d i n g s o l i d f o o d f e e d i n g . T h e a v a i l a b l e d a t a s u g g e s t that t h e m o t h e r s interpreted 'starting' the solid f o o d f e e d i n g p r o c e s s a s 'routinely' f e e d i n g s o l i d f o o d s , a n d not n e c e s s a r i l y a s t h e a g e that s o l i d f o o d s w e r e first i n t r o d u c e d . T h e r e f o r e , it s e e m s p o s s i b l e that t h e r e m a y b e a p r e l i m i n a r y period prior to e s t a b l i s h i n g routine f e e d i n g o r f o o d a c c e p t a n c e , w h e n the infant is b e i n g f e d s o l i d f o o d s ' s p o r a d i c a l l y ' . T h e c o n c e p t of ' s p o r a d i c ' v e r s u s 'routine' f e e d i n g of s o l i d f o o d s m a y or m a y not h a v e nutritional i m p l i c a t i o n s , d e p e n d i n g o n the infant's total diet a n d a g e . Further, the m o t h e r s ' r e a s o n s for starting s o l i d f o o d at t h e a g e t h e y c h o s e differed f r o m t h e r e a s o n s for s o l i d f o o d s e l e c t i o n . T h e m o t h e r s w e r e s t r o n g l y i n f l u e n c e d to start f e e d i n g their infant s o l i d f o o d s b y the following c o n d i t i o n s - the a d v i c e t h e y h a d r e c e i v e d , t h e infant's r e a d i n e s s a n d w a n t i n g the infant to s l e e p t h r o u g h the night.  In c o n t r a s t , f o o d s e l e c t i o n d e c i s i o n s w e r e c l e a r l y i n f l u e n c e d b y the  infant's a c c e p t a n c e o r rejection of t h e t y p e of s o l i d f o o d , o r b r a n d , offered a n d the m o t h e r ' s  55  RESULTS  concern about food allergies. T h e feeding process clearly appears to be influenced by many factors within the mother's proximate environment.  4.4.  Perceiving infant food needs T h e second theme in the 3-dimensional infant solid food feeding model is perceiving  infant food needs. T h e model (Figure 12) illustrates the link between the 2 themes - the feeding process and perceiving infant food needs. T h e 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. T h e 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. T h e interview data suggest that the mothers' perceptions and the infants' food responses 'caused' the mothers' subsequent solid food feeding behaviors.  56  RESULTS  The  F e e d i n g  Infant Ages  P r o c e s s  SOLID FOOD acceptance  Perceiving Infant Food Needs  9 mo.  SOLID FOOD rejection  •  Food Preferences (taste-texture)  6 mo,  t 4 mo. STARTING/ OFFERING  thefprocess solid food  Hunger  Readiness Developmental  / /  Figure 1 2 . T h e 3 - d i m e n s i o n a l infant s o l i d f o o d f e e d i n g m o d e l links t h e s e c o n d t h e m e 'perceiving infant food needs' with t h e p r e v i o u s t h e m e 'the feeding process'. T h e s e c o n d t h e m e i n c l u d e s 3 c o n c e p t s (the m o t h e r ' s p e r c e p t i o n of infant f o o d t a s t e a n d texture p r e f e r e n c e s , infant h u n g e r a n d d e v e l o p m e n t a l r e a d i n e s s s u c h a s risk of a l l e r g i e s o r c h o k i n g ) .  4.4.1. Perceiving infant 'readiness'. T h e m o t h e r ' s r e s p o n s e to h e r p e r c e p t i o n of h e r infant's r e a d i n e s s c u e s (both p h y s i c a l a n d c o g n i t i v e c u e s ) w a s to 'start' t h e s o l i d f o o d f e e d i n g p r o c e s s . T h e particular infant ' r e a d i n e s s ' c u e s m a n y m o t h e r s o b s e r v e d w e r e : r e a c h i n g o r trying to g r a b , turning h i s / h e r h e a d t o w a r d s f o o d , t a k i n g f o o d f r o m a s p o o n , sitting " p r o p p e d ' u p , b e i n g interested in f o o d , w a t c h i n g , f u s s i n g , b e i n g a "strong b i g k i d ' , g r o w i n g fast, a n d w a k i n g in t h e night. T h e f o l l o w i n g q u o t e is a n e x a m p l e of t h e  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)."  T h e 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. T h e 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)".  T h e mothers also observed specific infant behaviors and perceived them as characteristic of the infant not wanting solid foods. T h e 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. T h e 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  RESULTS b a c k in the infant's m o u t h a n d t h u s c a u s i n g him to retch a n d spit the f o o d up. T h e third q u o t e illustrates h o w infant f o o d r e f u s a l c o u l d i n f l u e n c e the f e e d i n g d y n a m i c s , or v i s e v e r s a , h o w feeding dynamics could influence food a c c e p t a n c e .  "[He] wouldn't  have any Pablum  (3-115)...  I would just keep offering  cereal and he kept turning it down and spitting, you know, like not opening of like retching (3-166)... clearly  him you know  rice  his mouth or just kind  on what you put in his mouth and so I just thought, oh, well he's not ready for food  He will always  taste what you have to offer... If he does not like what you offer he will  (3-611) shut his mouth and turn his head  "Started,  um, like the Pablum  (o'kay).  didn't seem to really take to it because  "From the beginning  (3-608).  We actually  tried it a little bit early...  he was still kind of spitting  at 4 V2 months  she just wouldn't  it out  (7-77).  He  (7-104)".  feed. She would turn her mouth  she'd  turn her head and she'd just fight it. And it was pretty much  ago  (12-252)".  that way up until about a  and  month  S e v e r a l m o t h e r s p e r c e i v e d that their infant w a s s h o w i n g 'interest' in f o o d (i.e., c o g n i t i v e r e a d i n e s s c u e s ) . T h e c o n c e p t 'becoming  interested  w a s articulated in the following two q u o t e s . .  It s e e m s p o s s i b l e that ' b e c o m i n g i n t e r e s t e d ' in s o l i d f o o d (learning to a c c e p t food) is a p r o c e s s o v e r t i m e that is i n f l u e n c e d b y t h e infant's d e v e l o p m e n t a l s t a g e , a g e a n d e x p o s u r e to f o o d . T h e c i r c u l a r a r r o w s within t h e m o d e l c o n n e c t i n g the m o t h e r - infant interaction a r o u n d f o o d d u r i n g t h e f e e d i n g p r o c e s s e m p h a s i z e that f e e d i n g is a d y n a m i c p r o c e s s . T h e m o t h e r ' s p e r c e p t i o n of h e r infant ' b e c o m i n g i n t e r e s t e d ' is p o s s i b l y a c a t a l y s t that 'triggers' h e r s u b s e q u e n t f e e d i n g d e c i s i o n s (starting/offering).  F u r t h e r o n in t h e results this c o n c e p t is p r e s e n t e d a g a i n with the f e e d i n g  s t r a t e g y 'waiting' b e c a u s e both c o n c e p t s a r e r e l a t e d . T h e m o t h e r s a p p e a r to b e 'waiting' for the infant to r e s p o n d o r b e c o m e i n t e r e s t e d in the f o o d that t h e y a r e b e i n g o f f e r e d .  "/ started She didn't actually  when  she was probably  become  interested  about 4 ¥2 months  until about...  (12-239)".  59  probably  but she was not interested  about four weeks  ago. At six  at all. months  RESULTS "He's really interested  in our food now and so once  giving them a little bit. Let them try it (10-599). well held off [for a] couple  of weeks  [I] started  they show  an interest and [you]  start  right at ~4 months... wasn't taking it too  (10-87)".  T h e a v a i l a b l e d a t a s u g g e s t that there m a y b e d i f f e r e n c e s in f e e d i n g p r a c t i c e s that a r e d e t e r m i n e d b y t h e m o t h e r ' s n e e d s rather t h a n t h e infant's f o o d c u e s . Interestingly, s e v e r a l m o t h e r s ' s o l i d f o o d f e e d i n g p r a c t i c e s a p p e a r e d to b e i n f l u e n c e d b y t h e m o t h e r herself 'wanting to f e e d ' s o l i d f o o d s . T h e m o t h e r ' w a n t i n g ' o r her ' r e a d i n e s s ' to f e e d s o l i d s c o u l d b e c o n s i d e r e d ' m o t h e r s ' r e a d i n e s s ' . It is not k n o w n f r o m t h e a v a i l a b l e d a t a w h a t t h e c o n s e q u e n c e s m a y b e for a n infant v e r s u s a m o t h e r d r i v e n f e e d i n g p r o c e s s . T h e following q u o t e illustrates h o w this m o t h e r ' s p e r c e p t i o n s a b o u t c e r e a l f e e d i n g i n f l u e n c e d her initial f e e d i n g p r a c t i c e s in a n e g a t i v e w a y . A s w e l l , t h e q u o t e e m p h a s i z e s t h e h i g h l e v e l of c o n c e r n t h e m o t h e r e x p e r i e n c e d w h e n h e r infant r e f u s e d c e r e a l . It s e e m s p o s s i b l e that m o t h e r s ' p e r c e p t i o n s a r e not o n l y d e t e r m i n e d by o b s e r v a t i o n of infant b e h a v i o r s at s p e c i f i c a g e s , but a l s o b y other f a c t o r s related to f o o d a n d f e e d i n g within t h e f e e d i n g c o n t e x t (i.e., p e r s o n a l f a c t o r s ) . F o r e x a m p l e , t h e m o t h e r b e l o w d e s c r i b e s h e r initial f e e d i n g b e h a v i o r s of f o r c i n g the infant to eat P a b l u m that h e a p p e a r e d to d i s l i k e , i n s t e a d of the toast h e a p p e a r e d to like.  "Pablum  which he never seemed  thinking I had to do this (1-48).  to really like but I kept trying to stuff in his  Just recently  I guess  we just I just go more liberal with stuff  just I said well why am I forcing him to eat this when look he is reaching actually  mouth,  for my toast right  he wants to taste that toast you know, so let him try it, that kind of thing  and now  (1-98)".  A further e x a m p l e of m o t h e r ' w a n t i n g ' or ' r e a d i n e s s ' to f e e d s o l i d s a n d p r o g r e s s in the f e e d i n g transition p r o c e s s is illustrated b y the following q u o t e . In this c a s e , the m o t h e r ' s p e r c e p t i o n s a b o u t her c o n t e x t (i.e., the w o r k l o a d of a s e c o n d c h i l d , g o i n g b a c k to work) a p p e a r e d to h a v e i n f l u e n c e d her s o l i d f o o d f e e d i n g d e c i s i o n s a n d her p r a c t i c e s . T h e m o t h e r d e s c r i b e s the i m p a c t of h a v i n g to return to w o r k o n 'the f e e d i n g p r o c e s s ' . H e r u s e of the p h r a s e " we becoming",  started  illustrates that a l t h o u g h t h e infant m a y b e ' r e a d y to start s o l i d f o o d s the m o t h e r m a y 1  60  RESULTS a l s o b e ' w a n t i n g ' to f e e d s o l i d f o o d s . T h e d u a l m e a n i n g of ' w a n t i n g / r e a d i n e s s ' highlights t h e interactional a s p e c t of solid f o o d f e e d i n g (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)".  A l t h o u g h m a n y m o t h e r s p e r c e i v e d their infants w e r e r e a d y for solid f o o d s b a s e d o n t h e b e h a v i o r s t h e y o b s e r v e d , t h e y s e e m e d t o b e p u z z l e d o r c o n c e r n e d w h e n t h e infant d i d not a c c e p t the s o l i d f o o d that t h e y o f f e r e d . S o m e m o t h e r s ' s o l i d f o o d f e e d i n g e x p e r i e n c e s c l e a r l y d i d not p r o g r e s s a s t h e y h a d e x p e c t e d b e c a u s e t h e infant r e f u s e d t h e f o o d . T h e first quote illustrates t h e m o t h e r ' s recognition of infant d e v e l o p m e n t a l r e a d i n e s s c u e s . H o w e v e r , there s e e m s to b e l e s s r e c o g n i t i o n of h e r infant's f o o d p r e f e r e n c e c u e s . T h e s e c o n d q u o t e illustrates a m o t h e r ' s frustration at h e r infant's f o o d r e s p o n s e . S h e d e s c r i b e s h e r f e e l i n g s in c o m p a r i s o n to h e r e x p e c t a t i o n s a n d h e r p e r c e p t i o n of h e r f r i e n d ' s infant's positive r e s p o n s e to t h e s o l i d f o o d s h e w a s b e i n g f e d . T h e s e m o t h e r s c o m p a r e d their infant with other infants that t h e y k n e w . T h e y r e m a r k e d o n t h e d i f f e r e n c e s b e t w e e n their infants. T h e interview d a t a s u g g e s t that m o t h e r s h a v e e x p e c t a t i o n s a b o u t t h e f e e d i n g p r o c e s s a n d that t h e s e e x p e c t a t i o n s m a y h a v e b e e n i n f l u e n c e d b y the c o m p a r i s o n s that t h e y m a k e a m o n g their p e e r s .  "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 m o t h e r s in this s t u d y o b s e r v e d w h a t t h e y p e r c e i v e d a s infant ' r e a d i n e s s ' c u e s . T h e c u e s t h e y o b s e r v e d a p p e a r e d to i n f l u e n c e their s u b s e q u e n t s o l i d f o o d f e e d i n g p r a c t i c e s , s u c h a s 'starting' s o l i d f o o d s . T h e m o t h e r s ' ' r e a d i n e s s ' to f e e d s o l i d f o o d o r start t h e transition p r o c e s s a p p e a r e d to a l s o b e a n i m p o r t a n t d e t e r m i n a n t of s o l i d f o o d f e e d i n g d e c i s i o n s . It i s not c l e a r f r o m the a v a i l a b l e d a t a if t h e infant's a c c e p t a n c e of s o l i d f o o d differs b e t w e e n a m o t h e r v e r s u s a n infant d r i v e n f e e d i n g p r o c e s s . Further, a l t h o u g h m a n y m o t h e r s identified infant c u e s that t h e y p e r c e i v e d a s t h e infant either b e i n g 'ready" o r not ' r e a d y f o r s o l i d f o o d s , t h e d i f f e r e n c e b e t w e e n 1  f o o d refusal c u e s (food p r e f e r e n c e s ) a n d ' r e a d i n e s s ' c u e s (not r e a d y for solids) a p p e a r e d to b e m o r e difficult f o r t h e m o t h e r s to d i s t i n g u i s h . T h e m o t h e r ' s ability to r e c o g n i z e f o o d ' r e a d i n e s s ' c u e s correctly is c l e a r l y critical, s i n c e solid f o o d f e e d i n g p r a c t i c e s (i.e. introduction a g e ) a p p e a r e d to b e i n f l u e n c e d b y infant f o o d c u e s .  4.4.2. Perceiving infant food 'preferences'. All of t h e m o t h e r s in this s t u d y d i s c u s s e d their o b s e r v a t i o n s of their infant's f o o d taste a n d texture p r e f e r e n c e s , w h i c h t h e y p e r c e i v e d a s a m a j o r d e t e r m i n a n t of their infant's a c c e p t a n c e of solid f o o d . T h e p h r a s e s u s e d to c o n v e y their p e r c e p t i o n s i n c l u d e d , " a n y t h i n g s w e e t [he likes]", " d o e s n ' t like t h e t a s t e " , " t o o tart", " a s t r o n g e r taste a n d h e liked t h a f , " it h a d a lot of f l a v o r [ m e a t ] ' , "metallic kind of t a s t e [meat in j a r s j ' , " s o that s h e is h a p p i e r t a k i n g it [cereal] w e try putting s o m e flavor into it for h e r " , " b l a n d ' a n d " rice [cereal] w a s t o o b o r i n g " .  T h e following q u o t e s illustrate t h e  p l a u s i b l e relationship b e t w e e n t h e m o t h e r ' s p e r c e p t i o n of h e r infant's taste p r e f e r e n c e s , h e r f e e d i n g s t r a t e g y a n d t h e final c o n s e q u e n c e - c e r e a l a c c e p t a n c e . T h e m o t h e r s c l e a r l y a p p e a r e d  62  RESULTS to h a v e b e e n 'tailoring' their f e e d i n g s t r a t e g i e s o v e r t i m e a c c o r d i n g to their f o o d related perceptions.  "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 m o t h e r s a l s o u s e d n u m e r o u s p h r a s e s to c o n v e y o b s e r v a t i o n s a n d p e r c e p t i o n s a b o u t f o o d texture p r e f e r e n c e . T h e m o t h e r s u s e d p h r a s e s s u c h a s ; " t h e c o n s i s t e n c y is a lot thicker [ c e r e a l ] " , " watery ', " r u n n y , " d o e s n ' t like the c h u n k y s t u f f - t h e f e e l [ p r e p a r e d f o o d s ] " , " s t r i n g y , 1  " t a c k y , " g r a i n y , " p u l p y , " [he's] not into h u n k s of a n y t h i n g " , " likes stuff fairly s m o o t h " , " t o o l u m p y a n d " h e really w a n t e d s o m e t h i n g a little bit s m o o t h e r " . T h e m o t h e r s e x p r e s s e d two distinct i d e a s within the 'texture p r e f e r e n c e s ' c o n c e p t . T e x t u r e w a s either e x p r e s s e d b y m o t h e r s a c c o r d i n g to solid f o o d t y p e s (i.e., d i f f e r e n c e s b e t w e e n c e r e a l s a n d m e a t s ) or a s a c o m p o n e n t of infant d e v e l o p m e n t (i.e., the infant's p r o g r e s s i o n f r o m o n e c o n s i s t e n c y to a n o t h e r , s u c h a s f r o m ' w a t e r y to 'thicker" c e r e a l o r p u r e e d to m a s h e d fruits a n d v e g e t a b l e s ) . T h e following t w o q u o t e s e m p h a s i z e t h e i m p o r t a n c e of f o o d t e x t u r e s to infant's p r e f e r e n c e s . T h e infant's a c c e p t a n c e of t h e s o l i d f o o d offered s e e m s to b e d e p e n d e n t o n the texture a n d flavor of the f o o d . T h e m o t h e r ' s f e e d i n g s t r a t e g i e s (i.e. mixing) a p p e a r e d to b e d e t e r m i n e d b y h e r p e r c e p t i o n s of what textures h e r infant liked a n d a c c e p t e d . Interestingly, t h e first q u o t e a l s o s u g g e s t s that t h e infant's p r o g r e s s i o n in f o o d texture m a y b e f o o d s p e c i f i c (i.e., v i s c o s i t y , f r o m runny a n d s m o o t h to t h i c k e r a n d l u m p i e r f o o d s ) . T h u s , p r o g r e s s i o n d u r i n g t h e f e e d i n g p r o c e s s f r o m p u r e e d to l u m p y f o o d s m a y differ d e p e n d i n g o n t h e i n d i v i d u a l f o o d f e d ( c e r e a l s , fruits, v e g e t a b l e s a n d m e a t s ) , b e c a u s e e a c h f o o d h a s u n i q u e texture c h a r a c t e r i s t i c s .  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 (6221-299)  "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 following q u o t e s illustrate h o w t h e m o t h e r s ' f o o d p e r c e p t i o n s i n f l u e n c e the ' w a y ' the infant is f e d . T h e s e m o t h e r s a r e u s i n g t h e f e e d i n g s t r a t e g y ' m i x i n g ' in r e s p o n s e to the infant's r e f u s a l of s o l i d f o o d . T h e f o o d p r e f e r e n c e s b e t w e e n t h e two infants, for w h o m t h e f o l l o w i n g q u o t e s refer, differ. T h e first q u o t e d e s c r i b e s a n infant w h o d i s l i k e d c e r e a l s , w h e r e a s the s e c o n d q u o t e d e s c r i b e s a n infant that d i s l i k e d a p p l e s a u c e , yet both m o t h e r s u s e d t h e c e r e a l fruit m i x i n g strategy in o r d e r t o p r o m o t e t h e d i s l i k e d f o o d ' s a c c e p t a n c e . It s e e m s p o s s i b l e that t h e infant's f o o d p r e f e r e n c e s , s u c h a s a d i s l i k e of s o m e iron-fortified c e r e a l s , m a y h a v e n e g a t i v e c o n s e q u e n c e s for the a m o u n t of f o o d c o n s u m e d . T h e m o t h e r s ' f e e d i n g strategy, with r e g a r d s to p r o m o t i n g s o l i d f o o d a c c e p t a n c e a p p e a r s to b e c l e a r l y 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 m o t h e r s ' p e r c e p t i o n s of their infants' f o o d t a s t e a n d texture p r e f e r e n c e s a p p e a r e d to b e a k e y d e t e r m i n a n t influencing their s o l i d f o o d f e e d i n g s t r a t e g i e s . C o n s e q u e n t l y , s i n c e t h e d a t a s u g g e s t that t h e m o t h e r s ' p e r c e p t i o n s of infant f o o d n e e d s w e r e related to f e e d i n g d e c i s i o n s it s e e m s p o s s i b l e that t h e m o t h e r s ' f e e d i n g s t r a t e g y m a y i m p a c t (promote o r d e c r e a s e ) the level of solid f o o d s t h e infant c o n s u m e s .  4.4.3. Perceiving infant 'hunger'. M a n y (8/12) of t h e m o t h e r s p e r c e i v e d that h u n g e r i n f l u e n c e d their infant's a c c e p t a n c e of solid f o o d . T h e f o l l o w i n g m o t h e r s f e d c e r e a l in t h e m o r n i n g to their 'hungry" infants, b e f o r e t h e y f e d a bottle of f o r m u l a a n d d e s c r i b e d h o w w e l l t h e infant a t e t h e c e r e a l in t h e m o r n i n g . T h e m o t h e r s u s e d p h r a s e s s u c h a s "timing is e v e r y t h i n g " , "if s h e ' s hungry s h e e a t s v e r y w e l l , s h e e a t s lots, s h e e a t s v e r y c o o p e r a t i v e l y a n d " s o m e t i m e s s h e ' s just not i n t e r e s t e d ' to d e s c r i b e their e x p e r i e n c e s . T h e a v a i l a b l e d a t a s u g g e s t that s o m e m o t h e r s a r e a w a r e of t h e c o n n e c t i o n b e t w e e n t h e length of t i m e b e t w e e n f e e d i n g s , h u n g e r a n d t h e s u b s e q u e n t a c c e p t a n c e of s o l i d 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 (5429)".  [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 m o t h e r s s e e m to adjust t h e t i m e b e t w e e n m e a l s in r e s p o n s e to their p e r c e p t i o n s a b o u t their infant's h u n g e r , w h e r e a s o t h e r m o t h e r s a p p e a r to find t h e m a n a g e m e n t of ' f e e d i n g '  65  RESULTS c h a l l e n g i n g . T h e first q u o t e d e s c r i b e s a 'flexible' s o l i d f o o d f e e d i n g style w h e r e the m o t h e r a p p e a r s to f e e d s o l i d s in r e s p o n s e to h e r infant's d e g r e e of h u n g e r . T h e m o t h e r in the s e c o n d q u o t e a p p e a r s to b e h a v i n g s o m e difficulty trying to ' c o o r d i n a t e ' t h e timing b e t w e e n t h e liquid a n d solid f o o d s in the diet. T h e s e q u o t e s reflect t h e d i f f e r e n c e s b e t w e e n the m o t h e r s ' f e e d i n g s t r a t e g i e s , e v e n t h o u g h their p e r c e p t i o n s a b o u t infant h u n g e r w e r e similar. T h e s e m o t h e r s a p p e a r e d to b e a w a r e of t h e i m p o r t a n c e of t h e timing b e t w e e n m e a l s a n d t h e infant's d e g r e e of h u n g e r . F u r t h e r , t h e y s e e m e d to b e a w a r e of t h e i m p o r t a n c e of the infant's d e g r e e of h u n g e r to subsequent food acceptance.  "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)".  L e a r n i n g to identify the infant's f o o d c u e s a p p e a r e d to b e a n important a n d o n g o i n g t a s k for m o t h e r s d u r i n g t h e f e e d i n g p r o c e s s . T h e following q u o t e highlights this a s p e c t of s o l i d f o o d f e e d i n g . T h e m o t h e r is c l e a r l y 'figuring out' o r d i s t i n g u i s h i n g b e t w e e n t h e v a r i o u s f o o d c u e s in o r d e r to u n d e r s t a n d h e r infant's r e f u s a l of f o o d . T h e a v a i l a b l e d a t a s u g g e s t that the m o t h e r s m o v e t h r o u g h 2 s t e p s w h e n ' p e r c e i v i n g their infant's f o o d n e e d s ' . T h e first s t e p i n v o l v e d g a i n i n g a n a w a r e n e s s of the ' s i g n s ' that infants m a y d i s p l a y d u r i n g the f e e d i n g p r o c e s s . T h i s a p p e a r e d to b e n e c e s s a r y for t h e m o t h e r s in o r d e r to start a s well a s to m a k e d e c i s i o n s t h r o u g h o u t the f e e d i n g p r o c e s s (e.g., i n t e r e s t e d , sitting up, r e a c h i n g a n d t a k i n g f o o d f r o m a s p o o n w e r e ' s i g n s ' m o t h e r s a s s o c i a t e d with s o l i d f o o d f e e d i n g ' r e a d i n e s s ' ) . T h e s e c o n d s t e p c o n s i s t e d of o b s e r v i n g a n d r e c o g n i z i n g the f o o d c u e s a n d t h e n d i s t i n g u i s h i n g b e t w e e n t h e m ( r e a d i n e s s , f o o d t a s t e a n d  66  RESULTS texture p r e f e r e n c e s , a n d h u n g e r ) . In o r d e r for t h e m o t h e r s to r e s p o n d a p p r o p r i a t e l y in their s u b s e q u e n t f e e d i n g s t r a t e g i e s t h e y c l e a r l y n e e d e d to u n d e r s t a n d their infant's f o o d c u e s . T h e following q u o t e d e s c r i b e s a m o t h e r l e a r n i n g to u n d e r s t a n d her infant's f o o d c u e s (not h u n g r y or d i s l i k e d w h a t w a s offered). In o r d e r for this m o t h e r to p r o m o t e s o l i d f o o d a c c e p t a n c e s h e c l e a r l y n e e d s to b e a b l e to d i s t i n g u i s h b e t w e e n t h e v a r i o u s f o o d c u e s that s h e is o b s e r v i n g .  " / want to try and figure out if... doesn't  is he hungry, oris he... is he not hungry  like the food you know at the time.  turning his head because he would be hungry  he doesn't  he just wasn't...  Whether  or is he just  he is you know he is turning his head is he  like it or is he turning it because he didn't like what we're feeding  he is full... Sometimes him  like  (10-827)".  T h e infant's f o o d c u e s a r e t h e e s s e n t i a l link to u n d e r s t a n d i n g their u n i q u e f o o d r e q u e s t s . D e s p i t e this i m p o r t a n c e , t h e reality is that t h e m o t h e r m u s t interpret t h e s e intricate a n d often m i x e d , f o o d c u e s , within the infant's c h a n g i n g e n v i r o n m e n t . T h e d a t a s u g g e s t that t h e r e m a y b e a ' p l a u s i b l e ' r e l a t i o n s h i p b e t w e e n t h e m o t h e r s ' p e r c e p t i o n s of h e r infants' f o o d n e e d s a n d h e r s u b s e q u e n t s o l i d f o o d f e e d i n g s t r a t e g i e s . H o w e v e r , a p p r o p r i a t e f e e d i n g r e s p o n s e s a p p e a r e d to b e highly i n f l u e n c e d b y if or to w h a t d e g r e e t h e m o t h e r u n d e r s t o o d h e r infant's f o o d c u e s .  4.5. Ways of feeding.  T h e third t h e m e in t h e 3 - d i m e n s i o n a l infant s o l i d f o o d f e e d i n g m o d e l is illustrated in F i g u r e 1 3 . T h e m o d e l links the 3 t h e m e s - the feeding to the third t h e m e - i v a y s of feeding.  process  a n d perceiving  infant food  needs,  W i t h i n the c o n t e x t of the s o l i d f o o d f e e d i n g p r o c e s s , h o w  the m o t h e r f e e d s h e r infant s o l i d f o o d s a p p e a r s to b e c o n t i n g e n t o n t h e f e e d i n g s t r a t e g y a n d / o r t e c h n i q u e ( s ) that s h e u s e s d u r i n g this p r o c e s s . T h u s , the third t h e m e identifies the m o t h e r s ' s o l i d f o o d f e e d i n g p r o c e d u r e s . F u r t h e r , t h e ' w a y t h e m o t h e r f e e d s h e r infant s o l i d f o o d s a p p e a r s to b e 5  s h a p e d , in part, b y h e r p e r c e p t i o n s of h e r infant's f o o d n e e d s a s well a s the infant's s o l i d f o o d a c c e p t a n c e o r rejection r e s p o n s e s . T h e s e r e l a t i o n s h i p s a r e illustrated in the 3 - d i m e n s i o n a l m o d e l . T h e m o t h e r ' s l e v e l of e x p e r t i s e o r f e e d i n g 'capability' a l s o a p p e a r e d to h a v e i n f l u e n c e d  67  RESULTS the ' w a y t h e infant w a s f e d . T h e relationship of the fourth t h e m e , ' g a i n i n g e x p e r t i s e ' , to t h e other 1  t h e m e s is d e s c r i b e d in t h e next s e c t i o n . T h e r a n g e of s o l i d f o o d f e e d i n g s t r a t e g i e s / t e c h n i q u e s that the m o t h e r s u s e d w e r e identified a n d d e s c r i b e d . F o u r t e e n f e e d i n g t e c h n i q u e s w e r e identified a n d l a b e l e d a s ; waiting, switching, eating, engaging, camouflaging,  mixing, adjusting playing,  positioning  prying/stuffing/  feeding  management,  (including  forcing, pushing  restraining), and holding  socializing,  modeling  distracting/sneaking  or  offering,  mimicking  or  back f o o d . T h e f e e d i n g  s t r a t e g i e s / t e c h n i q u e s d e s c r i b e t h e r a n g e of p r o c e d u r e s t h e m o t h e r s in this s t u d y u s e d to f e e d s o l i d f o o d s to their infants a n d potentially reflect the s o l i d f o o d f e e d i n g s k i l l s , inclination a n d c o m p e t e n c e (solid f o o d f e e d i n g capability) of t h e m o t h e r . Further, the a v a i l a b l e d a t a s u g g e s t that m a n y of t h e m o t h e r s w e r e ' a d a p t i n g ' their f e e d i n g s t r a t e g i e s / t e c h n i q u e s o v e r t i m e . T h e c o n c e p t ' a d a p t i n g ' reflects the interaction a r o u n d infant f e e d i n g ( m o t h e r - infant - food). T h e m o t h e r ' s infant f e e d i n g a c t i o n s (or r e a c t i o n s ) a p p e a r to b e in r e s p o n s e to s p e c i f i c c o n t e x t u a l f a c t o r s (the m o t h e r ' s p e r c e p t i o n s of infant f o o d n e e d s , t h e infant's r e s p o n s e to t h e s o l i d f o o d s f e d , t h e a g e of t h e infant, t h e level of f e e d i n g e x p e r t i s e a n d the e n v i r o n m e n t ) . T h u s , the m o t h e r a p p e a r s to h a v e b e e n 'tailoring' h e r f e e d i n g s t r a t e g i e s / t e c h n i q u e s b y ' a d a p t i n g ' the ' w a y s h e f e d h e r infant d u r i n g 1  t h e transition p r o c e s s . C o n s e q u e n t l y , t h e c o n c e p t ' a d a p t i n g ' c a n b e further d e s c r i b e d a l o n g a d i m e n s i o n s i n c e the m o t h e r m a y or m a y not d e c i d e to a d a p t t h e w a y s h e f e e d s h e r infant in r e s p o n s e to t h e u n i q u e c o n t e x t u a l f a c t o r s of h e r current s i t u a t i o n .  Interestingly, s p e c i f i c s o l i d  f o o d f e e d i n g s t r a t e g i e s / t e c h n i q u e s a p p e a r e d to i n f l u e n c e t h e a c c e p t a n c e of s o l i d f o o d s differently.  68  RESULTS  Ways of Feeding Dynamic T h e  F e e d i n g  P r o c e s s  Perceiving Infant Food Needs  Infant Ages  SOLID FOOD  9 mo.  acceptance  Food Preferences (taste-texture)  SOLID FOOD  6 mo.  rejection  . «\tchin9 . mixing . adjusting . engaging etc. s  Static repeatedly ottering liked toods . waiting . distracting  Hunger  etc.  4 mo.  Readiness Developmental  y  / /  STARTING/ thefprocess OFFERING solid food  / / /  Figure 13. T h e 3 - d i m e n s i o n a l infant s o l i d f o o d f e e d i n g m o d e l that links t h e third t h e m e , ways of feeding with t h e p r e v i o u s t w o t h e m e s , the feeding process a n d perceiving infant food needs. T h e third t h e m e identifies infant f e e d i n g s t r a t e g i e s that a p p e a r to b e d y n a m i c o r static in p r o m o t i n g solid 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 m o t h e r s articulated o n e ' w a y ' of f e e d i n g that w a s l a b e l e d a s 'offering'. T h e t e r m offering, in t h e c o n t e x t of t h e f e e d i n g p r o c e s s , reflects t h e m o t h e r ' s b e h a v i o r of r e p e a t e d l y offering p r e v i o u s l y r e j e c t e d f o o d to t h e infant. T h e infants of both of t h e m o t h e r s u s i n g this f e e d i n g s t r a t e g y d i d not a p p e a r to a c c e p t c e r e a l s f o r a m o n t h a n d a half o r l o n g e r . T h e transition g r a p h s ( A p p e n d i x G ) s u g g e s t that the infants w e r e a c c e p t i n g o n l y v e r y l o w l e v e l s of c e r e a l d u r i n g t h e t i m e w h e n t h e s e m o t h e r s w e r e r e p e a t e d l y 'offering' t h e p r e v i o u s l y r e j e c t e d c e r e a l s to their infants. T h e 'offering' s t r a t e g y / t e c h n i q u e is illustrated in t h e following q u o t e . It s e e m s p o s s i b l e that r e p e a t e d l y offering s o m e infants p r e v i o u s l y r e j e c t e d f o o d s d o e s not l e a d to its a c c e p t a n c e . It is a l s o p o s s i b l e that t h e m o t h e r s ' b e h a v i o r of r e p e a t e d l y 'offering' s o l i d f o o d s reflects a n infant d e v e l o p m e n t s t a g e w h e n t h e infant m a y b e 'testing' t h e f o o d . T h i s s t a g e m a y o c c u r prior to t h e infant's a c t u a l a c c e p t a n c e of t h e f o o d . If this w a s t h e c a s e , t h e quantity of s o l i d f o o d c o n s u m e d b y t h e infant d u r i n g t h e 'testing a n d offering' s t a g e w o u l d b e 'appropriately' l o w for t h e s t a g e . T h e following q u o t e w a s u s e d p r e v i o u s l y to illustrate t h e infant's l a c k of s o l i d f o o d a c c e p t a n c e . H e r e , the p u r p o s e of r e u s i n g this q u o t e is to e m p h a s i z e t h e m o t h e r ' s f e e d i n g t e c h n i q u e - r e p e a t e d offering a n d t h e c o n s e q u e n c e of t h e s t r a t e g y that w a s u s e d . In t h e c a s e of f o o d r e f u s a l , r e p e a t e d l y offering t h e s a m e s o l i d f o o d s to t h e infant m a y b e reflective of t h e m o t h e r not ' a d a p t i n g ' o r tailoring h e r f e e d i n g s t r a t e g y t o t h e infant's f o o d 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 (3166").... 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 feeding technique, labeled a s 'waiting' w a s described b y the following mother. T h i s t e c h n i q u e , a s t h e l a b e l s u g g e s t s , m e a n s t h e m o t h e r is 'waiting' for t h e infant to  70  RESULTS a c c e p t s p e c i f i c s o l i d f o o d s . T h e q u o t e s u g g e s t s that the m o t h e r m a y h a v e b e e n 'waiting' for the infant to ' b e c o m e i n t e r e s t e d ' in the infant c e r e a l that w a s b e i n g offered. Further, the m o t h e r s e e m s to h a v e b e e n waiting for t h e infant to a c c e p t t h e c e r e a l willingly. ' B e c o m i n g interested' is a 'cognitive r e a d i n e s s ' c u e that w a s d i s c u s s e d in the p r e v i o u s s e c t i o n . T h e m o t h e r a p p e a r s to b e ' a d a p t i n g ' her f e e d i n g s t r a t e g y in r e s p o n s e to h e r p e r c e p t i o n s of h e r infant's f o o d n e e d s . A t first s h e s t a t e s that s h e w o u l d ' g i v e in' a n d b r e a s t - f e e d h e r infant w h e n h e w a s not a c c e p t i n g e n o u g h c e r e a l a n d w a s c r y i n g . S h e t h e n l e a r n s to a d a p t h e r s t r a t e g y a n d d o e s not 'give in' a n d f e e d liquids i n s t e a d of the c e r e a l . T h e m o t h e r s e e m s to p e r c e i v e that her infant u n d e r s t a n d s that h e w o n ' t b e b r e a s t f e d in p l a c e of b e i n g f e d s o l i d f o o d . It s e e m s p o s s i b l e that t h e 'waiting' t e c h n i q u e m a y b e a k e y p r e l i m i n a r y s t e p in t h e p r o c e s s of the m o t h e r l e a r n i n g h o w to f e e d h e r infant s o l i d f o o d . In a n o t h e r q u o t e , this s a m e m o t h e r later u s e s the ' m i x i n g ' t e c h n i q u e to i n c r e a s e f o o d a c c e p t a n c e . T h e s e m o t h e r s s e e m s to b e 'tailoring' their f e e d i n g s t r a t e g y b y a d a p t i n g t h e ' w a y t h e y f e e d their infant in r e s p o n s e to t h e infant's f o o d 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 is his feed and  knows that this  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'.  ' S w i t c h i n g ' t y p e s a n d b r a n d s of c e r e a l s a n d ' m i x i n g ' c e r e a l s into c o m b i n a t i o n s w e r e identified a s the m o s t c o m m o n f e e d i n g s t r a t e g i e s / t e c h n i q u e s u s e d b y the m o t h e r s in this study. M a n y m o t h e r s d e s c r i b e d u s i n g t h e ' s w i t c h i n g ' (7/12) s t r a t e g y a n d the 'mixing' (6/12) s t r a t e g y in r e s p o n s e to their p e r c e p t i o n that their infant d i s l i k e d infant c e r e a l . H o w e v e r , all of the m o t h e r s  71  RESULTS (12/12) in this s t u d y d e s c r i b e d u s i n g t h e ' m i x i n g ' s t r a t e g y in o r d e r to c h a n g e the t a s t e o r texture of different f o o d s . T h e m o t h e r s w h o u s e d the f o o d ' s w i t c h i n g ' s t r a t e g y a l s o a p p e a r e d to d o s o to p r o m o t e s o l i d f o o d a c c e p t a n c e . F i v e of the s e v e n m o t h e r s in this g r o u p cited ' s w i t c h i n g ' a s a f e e d i n g s t r a t e g y that t h e y s p e c i f i c a l l y u s e d with c o m m e r c i a l infant c e r e a l s . O n e m o t h e r finally s w i t c h e d f o o d g r o u p s f r o m infant c e r e a l to s i n g l e fruit a n d v e g e t a b l e s b e f o r e the infant a c c e p t e d s o l i d f o o d s . A n o t h e r m o t h e r articulated ' s w i t c h i n g ' within h e r m e a t f e e d i n g p r a c t i c e s to p r o m o t e m e a t a c c e p t a n c e b y h e r infant. T h e f o l l o w i n g q u o t e s illustrate the c o m m o n f e e d i n g s t r a t e g y / t e c h n i q u e 'switching'.  T h e s e m o t h e r s s w i t c h e d to a n o t h e r t y p e of c e r e a l , for e x a m p l e , rice to oat c e r e a l ,  a n d b r a n d of c e r e a l , for e x a m p l e , M i l u p a to G e r b e r . T h e 3 m o t h e r s a r e c l e a r l y tailoring their f e e d i n g s t r a t e g i e s in r e s p o n s e to their infant's f o o d p r e f e r e n c e s .  "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 w e r e l e s s ' a c c e p t i n g ' of the c e r e a l s t h e y w e r e f e d . ' A c c e p t a n c e ' c a n b e identified b y t h e length of time it t a k e s the infant to eat t h e f o o d routinely. It s e e m s p o s s i b l e that the v a r i a t i o n s in the transition p a c e identified a m o n g t h e m o t h e r s m a y b e related to the u s e of s p e c i f i c f e e d i n g s t r a t e g i e s / t e c h n i q u e s . T h e m o t h e r in t h e last q u o t e (12-223) s t a t e d that it took a m o n t h a n d a half to finally find a c e r e a l t h e infant w o u l d eat. T h e following m o t h e r d e s c r i b e d the ' m i x i n g ' strategy. H o w e v e r , this q u o t e illustrates a n e g a t i v e c a s e s i n c e the infant c o n t i n u e d to r e f u s e the infant c e r e a l e v e n t h o u g h t h e m o t h e r u s e d t h e ' m i x i n g ' strategy. T h e transition g r a p h ( n u m b e r 3) ( A p p e n d i x G ) for this infant s h o w s c o n t i n u o u s l y low c e r e a l c o n s u m p t i o n b e t w e e n 5 a n d 7 m o n t h s of a g e . T h i s m o t h e r finally, after 2 m o n t h s , s w i t c h e d to giving fruit a l o n e rather  72  RESULTS t h a n m i x i n g fruit with c e r e a l . It is not c l e a r f r o m the a v a i l a b l e d a t a ' h o w ' the m o t h e r ' m i x e d ' the f o o d s together. A l t h o u g h infant c e r e a l a c c e p t a n c e a p p e a r s to b e i n c r e a s e d b y u s i n g t h e ' m i x i n g ' strategy, the w a y t h e m o t h e r m i x e s the f o o d s t o g e t h e r is a l s o c l e a r l y important.  "We have established to take it is by mixing doesn't  that he doesn't  like cereal and the only way we can really get  it with the fruit or vegetables.,  .but he will still turn it away (3-647).  like cereal, so I kind of think he was ready before...he  because  as soon as we offered  him a jarred pureed  just wasn't getting  him  He just  what he  wanted  fruit he loved it, he loved it... like right  away  (3-667)".  T h e m o s t f r e q u e n t 'way" that the m o t h e r s in this s t u d y 'tailored' their d a i l y f e e d i n g s t r a t e g y or t e c h n i q u e w a s b y 'mixing'foods.  S i m i l a r to ' s w i t c h i n g ' , the r e a s o n m o t h e r s g a v e for  m i x i n g f o o d s t o g e t h e r w a s to p r o m o t e f o o d a c c e p t a n c e . T h e f o l l o w i n g q u o t e s illustrate t h e m o t h e r a n d infant r e s p o n s e s , s p e c i f i c to f e e d i n g c e r e a l s a n d e m p h a s i z e the link b e t w e e n the t e c h n i q u e u s e d a n d t h e m o t h e r s ' p e r c e i v e d r e s p o n s e s . T h e s e c o n d q u o t e illustrates the c o m p l e x m i x t u r e s that the m o t h e r c r e a t e d in r e s p o n s e to h e r infant's r e f u s a l of s o l i d f o o d . T h e s e c o n d q u o t e a n d t h e p r e v i o u s q u o t e , a g a i n s u g g e s t that t h e ' w a y that the m o t h e r m i x e s f o o d s into 5  c o m b i n a t i o n s m a y h a v e d e c r e a s e d the a c c e p t a n c e of c e r e a l . T h e a v a i l a b l e d a t a s u g g e s t that it is c l e a r l y p o s s i b l e that t h e m o t h e r m a y c r e a t e m i x t u r e s that t h e infant d i s l i k e s .  "So he eats it much better now [cereal] with a vegetable  or I mix it with a fruit  "He takes oatmeal it with fruit to camouflage  someone always thought  liked Milupa maybe  (1-407)".  like the taste of it so we do have to mix  and with his dinner fruit and with his lunch fruit actually,  Initially he really liked it (rice/oatmeal Probably  ones the ones with banana, suggested  5 Vz months  cereals)  the ones with vegetable  and ya and then I started  mixing  wouldn't  in any cereal...  and I was you know and for some reason  I tried then  but  he's  it with a little bit of fruit juice and then I  do that but ahhh there is so many question  marks,  take, so then I don't know if that is what's given him a sweet tooth because  73  I just put it  and then he just  he wasn't interested  trying the Milupa and he didn't ever like Pablum  I shouldn't  So either I mix it  it. ..so I have been trying to give him a fair bit of cereal mixed with his  take them any more (4-235)... different  I will mix it..(1-140)...  and rice cereal and he doesn't  fruit, when he has breakfast, into all the fruit (4-70)  because  whatever  I started  they will  to mix  cereal  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  enough  for him or something  fruit....so doesn't  double  wammy  taking that then...about  so then I started  (4-242-268).  like the plain yogurt  Around  mixing  5 ¥2 months  then it wasn't  sweet  it I would mix it with fruit juice AND with his  the Cheerio  time started giving him yogurt  but he  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 ' m i x i n g ' w a s a c o n s i s t e n t t h e m e a c r o s s t h e i n t e r v i e w s . T h u s , ' m i x i n g ' t e c h n i q u e s w e r e s o r t e d in o r d e r to d e s c r i b e t h e m in m o r e detail. T h e m o t h e r s d e s c r i b e d 3 ' w a y s ' that f o o d m i x t u r e s w e r e f e d to their infants. It s e e m s p o s s i b l e that the different m i x i n g t e c h n i q u e s that the m o t h e r s u s e d c o u l d potentially i n f l u e n c e c e r e a l a c c e p t a n c e differently. T h e first m i x i n g variation d e s c r i b e d b y t h e m o t h e r s (4/12) w a s f e e d i n g ' c o m m e r c i a l l y p r e - m i x e d c o m b i n a t i o n s of infant c e r e a l o r m e a t with a d d e d fruit o r v e g e t a b l e s . T h e first q u o t e illustrates the first m i x i n g variation. T h e s e c o n d m i x i n g variation identified f r o m the sorting w a s w h e r e t h e m o t h e r (6/12) 'made her own mixture'  u s i n g s o m e c o m b i n a t i o n of b r e a s t milk, f o r m u l a , fruit, v e g e t a b l e s , o r  y o g u r t m i x e d with t h e 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 q u o t e illustrates t h e s e c o n d m i x i n g variation. In c o n t r a s t to t h e p r e v i o u s q u o t e , t h e s e q u o t e s illustrate i n c r e a s i n g infant c e r e a l acceptance.  "He just kind of, in the last week probably, Before  really kind of jumped  we would have been doing say, 2-3 tablespoons  tablespoons,  so he will have 4 tablespoons  either do the mixed cereal  with banana  "Twice a day morning vegetables.  of cereal  And I mix it with formula  eating more at about five months  quantities.  and now we are doing a full 3-a  in the morning...  or with mixed fruit  and night (cereal)...  up on his  full 4  I mix that with formula.,  we  (6-234)".  Just with fruit I have never mixed it with  too. I've been mixing  it with formula  umm since he  started  (8-121)".  T h e third m i x i n g variation d e s c r i b e d b y t h e m o t h e r s ' (4/12) w a s f e e d i n g infant c e r e a l with fruit or v e g e t a b l e s ' o n t h e s i d e ' of the plate d u r i n g t h e m e a l t i m e . T h e following q u o t e illustrates the ' o n the s i d e ' m i x i n g t e c h n i q u e . T h e s e q u e n c e that f o o d s a r e f e d is of particular interest, s i n c e the quantity of infant c e r e a l a c c e p t e d b y the infant m a y differ d e p e n d i n g o n the s e q u e n c e in w h i c h it is f e d . T h e m o t h e r s in t h e following q u o t e s f e d the infant c e r e a l after the o t h e r s o l i d  74  RESULTS f o o d s t h e y w e r e h a v i n g at that particular m e a l t i m e . It s e e m s p o s s i b l e that if infant c e r e a l s w e r e f e d last in a f e e d i n g s e q u e n c e , l e s s iron fortified infant c e r e a l m a y b e c o n s u m e d d u e to satiety.  "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 A and Ife or maybe 1/3 oatmeal 2/3 rds fruit I just use 1  oatmeal Milupa mixed with a wee bit of fruit juice (4-781)".  T h e q u o t e s illustrate v a r i a t i o n s in f o o d m i x t u r e s b e t w e e n m o t h e r s . T h e 3 ' w a y s ' of mixing c e r e a l s , a l t h o u g h slightly different, c o u l d b e c o n s i d e r e d a ' c o m p l e x ' f o o d c o m b i n a t i o n . Interestingly, of the n u m e r o u s f o o d m i x t u r e s f e d , n o n e of the m o t h e r s m i x e d infant c e r e a l s with m e a t s . T h e m o t h e r ' s m i x i n g c o m b i n a t i o n s m a y i n f l u e n c e infant a c c e p t a n c e a n d w o u l d differ in dietary iron c o n t e n t a n d f o o d c o m p o n e n t s that e n h a n c e o r inhibit iron a b s o r p t i o n . C l e a r l y , the f o o d ' m i x i n g ' t e c h n i q u e s that m o t h e r s u s e c o u l d i n f l u e n c e iron availability (i.e., d e p e n d i n g o n t h e infant's a c c e p t a n c e a n d t h e ratio a n d t h e t y p e s of f o o d s m i x e d together). T h e f o l l o w i n g q u o t e illustrates a m o t h e r 'tailoring' h e r f e e d i n g s t r a t e g y b y a d a p t i n g the f o o d mixture in r e s p o n s e to h e r infant's f o o d p r e f e r e n c e s . T h e total d i e t a r y iron c o n t e n t of the f o o d c o m b i n a t i o n f r o m this mixture is related to t h e ratio of h e m e iron p r o v i d e d f r o m the m e a t m i x e d with the a m o u n t of n o n - h e m e iron p r o v i d e d f r o m the v e g e t a b l e s . F o o d ' m i x t u r e ' v a r i a t i o n s - the ratio of fruit o r v e g e t a b l e s to c e r e a l o r m e a t , differed b e t w e e n the m o t h e r s in this s t u d y .  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 a v a i l a b l e d a t a s u g g e s t that the f e e d i n g t e c h n i q u e s 'offering' a n d 'waiting' m a y b e l e s s effective f e e d i n g s t r a t e g i e s t h a n ' s w i t c h i n g ' a n d ' m i x i n g ' at p r o m o t i n g infant c e r e a l a c c e p t a n c e . F u r t h e r , t h e infant's transition p a c e a p p e a r s to b e s l o w e r w h e n the f o r m e r s t r a t e g i e s w e r e u s e d . H o w e v e r , a l t h o u g h the ' m i x i n g ' f o o d t e c h n i q u e w a s d e s c r i b e d b y m a n y m o t h e r s a s o n e w a y of p r o m o t i n g infant c e r e a l a c c e p t a n c e , s e v e r a l m o t h e r s a p p e a r e d to h a v e s o m e difficulty c r e a t i n g m i x t u r e s that their infant a c c e p t e d .  4.5.3. Ways of feeding; adjusting feeding management  Half of the m o t h e r s in this s t u d y d e s c r i b e d u s i n g a f e e d i n g s t r a t e g y / t e c h n i q u e that w a s l a b e l e d ' a d j u s t i n g f e e d i n g m a n a g e m e n t ' a s a 'way" to p r o m o t e s o l i d f o o d a c c e p t a n c e (i.e. c e r e a l ) . T h e m o t h e r s d e s c r i b e d two different f e e d i n g m a n a g e m e n t b e h a v i o r s . T h e m o t h e r s ' b e h a v i o r s i n c l u d e d either limiting t h e liquid f o o d in the diet a n d / o r a d j u s t i n g the timing b e t w e e n f e e d i n g s . T h e following q u o t e s illustrate t h e ' w a y that t h e s e m o t h e r s w e r e 'tailoring' their f e e d i n g strategy in o r d e r to p r o m o t e c e r e a l a c c e p t a n c e . T h e f o l l o w i n g t w o m o t h e r s d i s c u s s e d limiting the liquid portion ( b r e a s t m i l k , f o r m u l a ) of t h e 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 (5429)".  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 (11343) 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 following s t a t e m e n t s highlight t h e c o n n e c t i o n b e t w e e n the m o t h e r ' s f e e d i n g strategy a n d her p e r c e p t i o n of the f e e d i n g e x p e r i e n c e ; "it's m o r e r e l a x e d that w a y . . . n o t h a v i n g to rush a r o u n d ' a n d " h e definitely e n j o y s his f o o d m o r e " . T h e m o t h e r s s e e m e d to f e e l , in particular, that 'eating together" w a s a n important f a c t o r that i n c r e a s e d the infant's m e a l t i m e e n j o y m e n t . O n e m o t h e r in this g r o u p articulated a d e t a i l e d a c c o u n t of t h e f o u r t e c h n i q u e s in this s e c t i o n . T h e text h a s b e e n i n c l u d e d to illustrate the u s e of multiple ' s o c i a l ' f e e d i n g t e c h n i q u e s ( A p p e n d i x 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 (10894/909)."  "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 f e w m o t h e r s d e s c r i b e d a f e e d i n g t e c h n i q u e that w a s l a b e l e d a s ' p o s i t i o n i n g ' . T h e first q u o t e illustrates h o w o n e m o t h e r a d a p t e d h e r f e e d i n g s t r a t e g y b y c h a n g i n g the ' p o s i t i o n ' that the infant w a s f e d . T h e infant w a s f e d w h i l e lying flat o n h i s b a c k rather t h a n sitting u p to eat, in o r d e r to i n c r e a s e the quantity of s o l i d s h e r infant c o n s u m e d . T h e m o t h e r u s e d this t e c h n i q u e for the first m o n t h of f e e d i n g c e r e a l a n d s t a t e d that the infant a t e a l a r g e r quantity a n d ate h a p p i l y in this p o s i t i o n . T h e s e c o n d q u o t e illustrates a n o t h e r e x a m p l e of the m o t h e r a d a p t i n g h e r f e e d i n g s t r a t e g y (the ' p o s i t i o n i n g ' t e c h n i q u e ) to get f o o d e a t e n b y the infant. In this c a s e the m o t h e r  78  RESULTS a p p e a r s to b e 'restraining' the infant in a c a r s e a t to c a l m h i m e n o u g h to get him to drink a bottle. T h i s m o t h e r e x p r e s s e d c o n c e r n a b o u t the difficulty of f e e d i n g s o l i d f o o d c o m p a r e d with giving a bottle. B o t h of t h e f o l l o w i n g q u o t e s a r e e x a m p l e s of t h e 'positioning' t e c h n i q u e . T h e a v a i l a b l e d a t a s u g g e s t that a l t h o u g h f e e d i n g in t h e 'lying p o s i t i o n ' m a y i n c r e a s e s o l i d f o o d c o n s u m p t i o n for this particular infant, ' r e s t r a i n i n g ' the infant a n d f e e d i n g liquid f o o d s r e p l a c e s the s o l i d s a n d m a y d e l a y t h e s o l i d f o o d transition 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 m o t h e r s d e s c r i b e d u s i n g a f e e d i n g t e c h n i q u e that w a s l a b e l e d a s 'distracting'. T h e m o t h e r s u s e d f o o d t o y s to distract the infant w h i l e s p o o n - f e e d i n g , in o r d e r to get t h e infant to eat t h e s o l i d f o o d . B o t h m o t h e r s , in the following q u o t e s , p e r c e i v e d that the infant e n j o y e d 'chewing' on the food toys during the mealtime.  "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.... (7662)".  79  RESULTS "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 m o t h e r s a l s o d e s c r i b e d a n infant f e e d i n g t e c h n i q u e that w a s l a b e l e d a s ' s n e a k i n g ' or ' c a m o u f l a g i n g ' . T h e m o t h e r s a p p e a r e d to b e tailoring their f e e d i n g s t r a t e g y b y s n e a k i n g ( c h a n g i n g f e e d i n g s e q u e n c e ) or c a m o u f l a g i n g (mixing d i s l i k e d with liked f o o d s ) the s o l i d f o o d . F o r e x a m p l e , the f o l l o w i n g m o t h e r f e d the ' l e s s a c c e p t e d ' m e a t rice c o m b i n a t i o n b e f o r e the ' a c c e p t e d ' y a m s . T h e m o t h e r in t h e s e c o n d q u o t e , m i x e d liked a n d d i s l i k e d f o o d s together, in o r d e r to hide or c a m o u f l a g e t h e d i s l i k e d s o l i d f o o d in the c o m b i n a t i o n . T h e f o o d ' m i x i n g ' t e c h n i q u e h a s b e e n p r e v i o u s l y d i s c u s s e d . M i x i n g f o o d s t o g e t h e r into c o m p l e x f o o d c o m b i n a t i o n s m a y p o s s i b l y h a v e 2 different o u t c o m e s . A s p r e v i o u s l y d e s c r i b e d , t h e m i x i n g t e c h n i q u e s e e m s to b e u s e d b y m o t h e r s to tailor the t a s t e or texture of the f o o d c o m b i n a t i o n , in r e s p o n s e to t h e infant's f o o d p r e f e r e n c e s . T h u s , p r o m o t i n g s o l i d f o o d a c c e p t a n c e . Alternately, in this c a s e , the f o o d ' m i x i n g ' t e c h n i q u e a p p e a r s to f o c u s o n s n e a k i n g or c a m o u f l a g i n g d i s l i k e d f o o d s with f o o d s the infant likes. It is not c l e a r if, o r to w h a t d e g r e e , the f o o d is a c c e p t e d b y the infant, u s i n g this strategy.  Further, it is not c l e a r , but s e e m s p o s s i b l e , that l o n g e r t e r m e n j o y m e n t of s p e c i f i c s o l i d  f o o d s m a y d e c r e a s e w h e n u s i n g t h e s e s t r a t e g i e s - distracting, s n e a k i n g / c a m o u f l a g i n g .  '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 f e w m o t h e r s (3/12) c o m m e n t e d o n their initial u s e of a f e e d i n g t e c h n i q u e that w a s l a b e l e d prying, stuffing or f o r c i n g s o l i d f o o d . T h e e x p r e s s i o n s u s e d b y m o t h e r s to d e s c r i b e t h e s e t e c h n i q u e s w e r e " pry with m y s p o o n , s h o v e the f o o d in, a n d w h y a m I forcing him to eat this".  80  RESULTS T h e s e m o t h e r s a p p e a r to h a v e u s e d t h e s e s t r a t e g i e s initially, a n d t h e n later tailored their f e e d i n g t e c h n i q u e s (or m a y b e a d j u s t e d their p e r c e p t i o n s a b o u t their infant's f o o d n e e d s ) in r e s p o n s e to w h a t a p p e a r e d to b e n e g a t i v e f e e d i n g d y n a m i c s . T h e following q u o t e s u g g e s t s that the m o t h e r s e e m s to b e c o n c e r n e d a b o u t the infant not 'getting e n o u g h ' f o o d a n d not e a t i n g c e r e a l . A m o t h e r ' s ' c o n c e r n ' a b o u t s o l i d f o o d rejection m a y i n c r e a s e t h e u s e of t h e s e s p e c i f i c f e e d i n g t e c h n i q u e s (forcing, prying a n d p u s h i n g s o l i d f o o d s ) . T h e following q u o t e a l s o s e e m s to s u g g e s t that t h e m o t h e r is i n e x p e r i e n c e d in f e e d i n g a n d that s h e is m o v i n g t h r o u g h a learning ' p r o c e s s ' p o s s i b l y trying t o f i g u r e out ' h o w ' to f e e d h e r 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 start putting it [a toy] in his mouth  and I would shove  know that (2-1057)...  being  I remember  him cereal and he wouldn't doing it (2-1169  )...Like  and I would shove shook something doesn't  about, like initially, I guess,  take it and I tried to pry my spoon,  food in (2-1064)...  But you are not supposed  just to try to get his mouth want it. I mean,  has to eat, and you now ummmm much, and that means  the food in. But you are not supposed  but I know I shouldn't  open ... so I can feed him (2-1088)...  the books say you should  giving  have  to know that (1065)...  he's not going to starve.  to  when we were  he would play with this [toys] and he would start putting it in his  want it he doesn't  been mouth  Just like.. .[I]  I mean,  if he  But initially you think, oh, he  get so much of this, so much fruit, so  you have to go by. But I mean ifs not a big deal, you know, one day he  just eats, you know, crackers  4.5.8. Ways of feeding; 'Pushing'  worried  would  and toast  (2-1174-1183)".  pushing  w a s a s t r o n g t h e m e that e v o l v e d f r o m a c r o s s m o r e t h a n half of t h e i n t e r v i e w s  (8/12). T h e c o n c e p t ' p u s h i n g ' h a s 2 different interpretations. T h e m o t h e r s a p p e a r e d to b e ' p u s h i n g ' t h e s o l i d f o o d itself a n d / o r ' p u s h i n g ' the transition p a c e , f r o m a liquid to a m i x e d f o o d diet. T h e t w o r e a s o n s for ' p u s h i n g ' f o o d s w e r e c o n c e r n a b o u t returning to w o r k a n d c o n c e r n a b o u t t h e infant's o u t c o m e (food r e f u s a l a n d weight g a i n ) . It s e e m s p o s s i b l e that ' p u s h i n g ' f o o d or the transition p a c e m a y reflect t h e m o t h e r s ' r e s p o n s e to s o l i d f o o d f e e d i n g c o n c e r n s in g e n e r a l . T h e m o t h e r ' s w o r k f o r c e participation a p p e a r s to h a v e i n f l u e n c e d , to s o m e d e g r e e , s u b s e q u e n t f e e d i n g b e h a v i o r s . F o u r m o t h e r s in this s t u d y w e r e intending to o r h a d a l r e a d y  81  RESULTS returned to w o r k . T h e a v a i l a b l e d a t a s u g g e s t t h e m o t h e r s w e r e ' p u s h i n g ' t h e transition p r o c e s s in o r d e r to return to work. T h e s e m o t h e r s u s e d p h r a s e s like, " w o n ' t h a v e to w o r r y ' , a n d " s o that I c o u l d k n o w that h e w o u l d b e fine w h e n I w a s a w a y , to e x p r e s s s o m e of t h e e m o t i o n a l a n d o r g a n i z a t i o n a l i s s u e s a r o u n d s o l i d f o o d f e e d i n g a n d l e a v i n g their infant, in o r d e r to return to w o r k . T h e first two q u o t e s illustrate t h e i m p a c t of returning to w o r k o n t h e s e m o t h e r s ' s o l i d f o o d f e e d i n g p r a c t i c e s . It s e e m s p o s s i b l e , that t h e p o s t n a t a l time line w h e n t h e m o t h e r m u s t return to work, m a y i n f l u e n c e t h e a g e s o l i d f o o d s a r e i n t r o d u c e d a s well a s t h e p a c e m o t h e r s 'transition' from t h e liquid diet to a m i x e d diet that i n c l u d e s s o l i d f o o d s .  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 (11084)... 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 f o l l o w i n g m o t h e r s t a t e d that s h e w o u l d not b e a b l e to return to w o r k w h e n s h e e x p e c t e d b e c a u s e of t h e difficulty s h e w a s e x p e r i e n c i n g with t h e s o l i d f o o d transition p r o c e s s . T h e following q u o t e s u g g e s t s s h e is c o n c e r n e d a b o u t , t h e quantity of s o l i d f o o d s h e r infant is a c c e p t i n g , h o w q u i c k l y h e is p r o g r e s s i n g in t h e transition p r o c e s s a n d t h e infant's refusal of infant f o r m u l a in a bottle.  82  RESULTS / 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, t h e following m o t h e r s e e m s to b e tailoring h e r infant f e e d i n g routines to t h e future d a i l y routines s h e e x p e c t s to h a v e w h e n s h e returns to w o r k . T h e s e c o m m e n t s reflect t h e c o m p l e x e m o t i o n a l a n d o r g a n i z a t i o n a l i s s u e s i n v o l v e d in t h e m o t h e r ' s p r e p a r a t i o n to return to w o r k . T h e link b e t w e e n t h e ' c o n s i s t e n c y of d a i l y f e e d i n g routines' a n d t h e infant's a s w e l l a s t h e c a r e g i v e r ' s ' e x p e c t a t i o n s ' a b o u t f e e d i n g a p p e a r e d to b e important to this mother, in o r d e r to m a k e h e r transition f r o m b e i n g at h o m e to b e i n g a t w o r k , e a s i e r . F u r t h e r , t h e mother, a s t h e q u o t e s u g g e s t s , m u s t 'transition' f r o m b e i n g t h e p r i m a r y f e e d e r to h a v i n g a c a r e g i v e r t a k e o v e r t h e f e e d i n g 'role', d u r i n g t h e d a y t i m e . T h e m o t h e r a p p e a r s to b e c o n s c i o u s l y tailoring h e r f e e d i n g r o u t i n e s in o r d e r to ' p u s h ' o r p r o m o t e a s u c c e s s f u l transition f o r w h e n s h e returns to w o r k .  "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 m o t h e r s ' (3/12) a p p e a r e d to b e tailoring their f e e d i n g s t r a t e g y b y ' p u s h i n g ' f o o d b e c a u s e of their p e r c e p t i o n s a b o u t t h e infant not g a i n i n g w e i g h t a n d / o r not a c c e p t i n g f o o d s . T h e s e m o t h e r s u s e d p h r a s e s s u c h a s " s t o p p e d g a i n i n g " , "trying to f e e d h i m a lot" a n d " I w a s really w o r r i e d ' to e x p r e s s their c o n c e r n . T h e first q u o t e illustrates t h e m o t h e r ' s f o o d s p e c i f i c ' p u s h i n g ' b e h a v i o r w h e r e s h e s e e m s to tailor h e r liquid f e e d i n g s t r a t e g y to " f e e d h i m a lot" b e c a u s e s h e i s " w o r r i e d a b o u t w e i g h t ' . T h e s e c o n d q u o t e d e s c r i b e s a m o t h e r not ' p u s h i n g ' s o l i d s but i n s t e a d 'waiting' for t h e infant to ' b e c o m e i n t e r e s t e d ' in c e r e a l s . It is p o s s i b l e that t h e f o o d  83  RESULTS 'pushing' strategy would develop further, with dimensions ranging from' pushing' to not 'pushing' or 'waiting', with more focused interviewing and analysis. It s e e m s 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 (12526)."  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. T h e 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). T h e 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. T h e following two quotes illustrate the mothers'  84  RESULTS c o n c e r n a b o u t texture a n d c h o k i n g . T h e m o t h e r s c o n c e r n s e e m s to i n f l u e n c e the infant f e e d i n g p r o c e s s - t h e introduction of s p e c i f i c s o l i d f o o d s a n d t h e transition 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) m o t h e r s c o m m e n t e d o n h o l d i n g b a c k f o o d s 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 t h e f o o d a n d risk of tooth d e c a y , with r e g a r d s to j u i c e , w a s a c o m m o n c o n c e r n . S p e c i f i c f o o d s not b e i n g a s nutritious a s o t h e r s , w a s a l s o a c o n c e r n (i.e., r e d m e a t s o r fruit not b e i n g a s nutritious a s white m e a t s o r v e g e t a b l e s ) . P r o c e s s e d c o m m e r c i a l f o o d s with i n g r e d i e n t s s u c h a s p r e s e r v a t i v e s , w e r e a c o n c e r n to s o m e m o t h e r s . L a s t l y , c o n c e r n a b o u t future weight p r o b l e m s , w a s d i s c u s s e d . T h e f o l l o w i n g q u o t e s illustrate h o w t h e m o t h e r m a y tailor h e r f e e d i n g s t r a t e g y a c c o r d i n g to h e r p e r c e p t i o n s a b o u t t h e ' c h a r a c t e r i s t i c s of t h e f o o d ' . T h e q u o t e s a l s o s u g g e s t that t h e s e m o t h e r s a p p e a r t o b e i n f l u e n c e d b y w h a t t h e y p e r c e i v e d w a s 'healthy a n d 1  'nutritious' f o o d .  "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  RESULTS 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 m o t h e r s h e l d b a c k s p e c i f i c f o o d s ( m i x e d c e r e a l s , fruits, a n d dairy) b e c a u s e of their p e r c e p t i o n s a b o u t t h e risk of a f o o d allergy. T h e f o o d ' s a l l e r g y 'likelihood' s e e m e d to influence the mothers' d e c i s i o n s about what w a s fed. T h e mothers who were c o n c e r n e d about a l l e r g i e s c o m m e n t e d o n w h a t not to g i v e their infant at s p e c i f i c a g e s (e.g., m i x e d c e r e a l s a n d dairy). T h e following q u o t e a l s o i n t r o d u c e s the c o n c e p t of f e e d i n g ' o n e f o o d at a time' b e f o r e m o v i n g o n to a different f o o d . It s e e m s highly likely that m o t h e r s will differ in their f e e d i n g p r a c t i c e s with r e g a r d s to s o l i d f o o d p r o g r e s s i o n . F e e d i n g ' o n e f o o d at a time' before m o v i n g o n to a different f o o d m a y d e c r e a s e t h e transition p a c e , d e p e n d i n g o n h o w the m o t h e r 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 m o t h e r s c o m m e n t e d o n ' h o l d i n g b a c k ' m e a t s , h o w e v e r , they did s o for different r e a s o n s . T h e first q u o t e illustrates t h e i n f l u e n c e of the m o t h e r ' s p e r c e p t i o n of infant d e v e l o p m e n t a l r e a d i n e s s ( b e i n g h a r d o n the infant's s t o m a c h ) o n f e e d i n g d e c i s i o n s , w h e r e a s t h e s e c o n d q u o t e s u g g e s t s that t h e f o o d (meat) availability m a y i n f l u e n c e the m o t h e r ' s m e a t f e e d i n g practices.  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 (10247)". " D o e s n ' t ' get protein e v e r y d a y [ c o m m e r c i a l l y p r e p a r e d m e a t combinations]...if w e ' v e got o n e o p e n . . . [ W e ] u s e [it] up o n c e [its]opened ( 1 1 - 8 0 5 ) " .  T w o m o t h e r s c o m m e n t e d o n t h e i d e a of 'potentially' influencing infant f o o d p r e f e r e n c e s b y ' h o l d i n g b a c k ' s p e c i f i c f o o d s . T h e f o l l o w i n g t w o m o t h e r s both 'limited' t h e liquids in their infant's diet (formula a n d b r e a s t milk), in o r d e r to i n f l u e n c e c e r e a l a c c e p t a n c e . T h e first m o t h e r a l s o ' h e l d b a c k ' fruits b e c a u s e s h e p e r c e i v e d that it w o u l d i n f l u e n c e o r p r o m o t e h e r infant's a c c e p t a n c e of v e g e t a b l e s . 'Limiting" t h e liquid portion of t h e diet w a s p r e v i o u s l y d i s c u s s e d in t h e section discussing the feeding technique 'adjusting feeding management'. T h e quotes are p r e s e n t e d h e r e to e m p h a s i z e t h e similarity b e t w e e n t h e t w o c o n c e p t s - h o l d i n g b a c k f o o d a n d limiting f o o d . H o l d i n g b a c k f o o d s , a s d i s c u s s e d in this s e c t i o n , is a t e c h n i q u e that m o t h e r s u s e , s p e c i f i c a l l y , b e c a u s e of their p e r c e p t i o n s a b o u t t h e c h a r a c t e r i s t i c s of t h e f o o d itself ( c o n c e r n a b o u t c h o k i n g , texture difficulty, a l l e r g y risk, tooth d e c a y , f o o d p r o c e s s i n g c o n c e r n s , difficult to d i g e s t , a n d f o o d availability). T h e m o t h e r s w h o a d j u s t e d their f e e d i n g m a n a g e m e n t b y 'limiting' o r ' h o l d i n g b a c k ' liquids o r o t h e r f o o d s u c h a s fruit a p p e a r e d t o d o s o t o i n f l u e n c e t h e infants' f o o d p r e f e r e n c e s . T h e 2 c o n c e p t s - limiting a n d h o l d i n g b a c k m a y d e v e l o p a l o n g a d i m e n s i o n within the 'adjusting' f e e d i n g m a n a g e m e n t t e c h n i q u e with further interviewing a n d a n a l y s 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 (12000)... 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  RESULTS 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 n u m b e r of s o l i d f o o d f e e d i n g s t r a t e g i e s u s e d b y t h e individual m o t h e r s v a r i e d f r o m 2 to 7 ( A p p e n d i x I). A l t h o u g h the a b s o l u t e n u m b e r of s t r a t e g i e s u s e d b y e a c h m o t h e r m a y , to s o m e d e g r e e , reflect that t h e m o t h e r is tailoring h e r infant f e e d i n g strategy, it d o e s not c o n v e y h o w t h e different s t r a t e g i e s that the m o t h e r u s e s c o u l d potentially i n f l u e n c e dietary o u t c o m e differently. T h e s u m m a r y of f e e d i n g s t r a t e g i e s in T a b l e 2 lists 14 s t r a t e g i e s / t e c h n i q u e s that the m o t h e r s in this s t u d y u s e d to f e e d their infants. T h e s u m m a r y s u g g e s t s that t h e m o t h e r s in this s t u d y u s e d a w i d e r a n g e of s o l i d f o o d f e e d i n g s t r a t e g i e s .  A summary of mothers' solid food feeding strategies 1.  offering t h e s a m e f o o d ( r e p e a t e d l y offering d i s l i k e d f o o d s )  2.  w a i t i n g (initially s t o p p i n g o r g i v i n g up)  3.  s w i t c h i n g (food t y p e s a n d / o r b r a n d s )  4.  m i x i n g (to alter t a s t e o r textures)  5.  a d j u s t i n g f e e d i n g m a n a g e m e n t (feeding routines)  6.  s o c i a l i z i n g (family m e a l s )  7.  m o d e l i n g o r m i m i c k i n g ( t e a c h i n g infant h o w to eat)  8.  e n g a g i n g (giving s o m e d e g r e e of control to t h e infant d u r i n g f e e d i n g )  9.  p l a y i n g (food play)  10. p o s i t i o n i n g (feeding lying o n b a c k , restraining in c a r s e a t ) 1 1 . d i s t r a c t i n g , s n e a k i n g or c a m o u f l a g i n g ( u s i n g t o y s a s d i s t r a c t e r s d u r i n g f e e d i n g to get f o o d e a t e n , m i x i n g r e j e c t e d s o l i d f o o d s with a c c e p t e d s o l i d f o o d s to get f o o d eaten) 1 2 . p r y i n g ( m o u t h o p e n ) , stuffing/forcing (solid f o o d into mouth) 1 3 . p u s h i n g (specific f o o d s or f e e d i n g transition p a c e ) 14. h o l d i n g b a c k ( s p e c i f i c f o o d s )  T a b l e 2.  A s u m m a r y of the s o l i d f o o d f e e d i n g s t r a t e g i e s u s e d b y m o t h e r s in this study.  88  RESULTS T h e s u m m a r y e x p a n d s o u r u n d e r s t a n d i n g of the ' w a y s ' that m o t h e r s f e e d their infants a n d h o w t h e y 'tailor* their f e e d i n g s t r a t e g i e s in r e s p o n s e to their o w n p e r c e p t i o n s , the infants' c u e s a n d t h e ' c o n d i t i o n s ' within t h e infant f e e d i n g c o n t e x t . T h i s p r o v i d e s a better u n d e r s t a n d i n g of t h e link b e t w e e n the p r o c e d u r e s of infant f e e d i n g ( s t r a t e g i e s / t e c h n i q u e s ) , infant f o o d a c c e p t a n c e a n d the f e e d i n g p r o c e s s . F u r t h e r , a n u n d e r s t a n d i n g of the d e t e r m i n a n t s of infant f o o d a c c e p t a n c e , in particular, iron fortified c e r e a l s , e n h a n c e s o u r u n d e r s t a n d i n g of d e t e r m i n a n t s of dietary iron c o n s u m p t i o n o v e r t i m e , f r o m this s o u r c e . T h e s u m m a r y p r o v i d e s a u s e f u l list of potential f e e d i n g s t r a t e g i e s that c o u l d b e further d e s c r i b e d a l o n g a c o n t i n u u m of s t r a t e g i e s that p o s s i b l y p r o m o t e or d i s c o u r a g e iron fortified infant c e r e a l a c c e p t a n c e . C l e a r l y , s o m e f e e d i n g s t r a t e g i e s w e r e l e s s effective t h a n o t h e r s t r a t e g i e s . T h e a v a i l a b l e d a t a s u g g e s t that the 'way* the infant w a s f e d m a y h a v e i n f l u e n c e d t h e s u b s e q u e n t a c c e p t a n c e of the s o l i d f o o d s .  89  RESULTS  4.6. Gaining expertise  T h e fourth t h e m e in the 3-dimensional s o l i d f o o d infant f e e d i n g m o d e l is illustrated in  Figure 14. T h e m o d e l n o w links the 4 t h e m e s - the feeding process, needs,  ways of feeding,  to the fourth t h e m e gaining  expertise.  perceived  infant  food  T h e f e e d i n g p r o c e s s a p p e a r s to  b e i n f l u e n c e d b y the m o t h e r ' s infant f e e d i n g k n o w l e d g e , skills a n d c o n f i d e n c e d e v e l o p e d d u r i n g this transition p r o c e s s . T h u s , the m o t h e r s ' p e r s o n a l learning w a s l a b e l e d ' g a i n i n g e x p e r t i s e ' . T h e five m a i n c o m p o n e n t s to this t h e m e i n c l u d e , finding a n d u s i n g r e s o u r c e s , b e i n g a first t i m e m o t h e r a n d f e e l i n g s c a r e d , s e e k i n g r e a s s u r a n c e , a n d learning t h r o u g h trial a n d error.  90  RESULTS  Ways of Feeding Perceiving Infant Food Needs  Food Preferences (taste-texture)  Hunger  Dynamic . switching . mixing . adjusting . engage etc. Static .repeatedly ottering disliked toods . waiting . distracting  etc. Readiness Deveiopmentai  y < f f 4  Figure 14. T h e 3 - d i m e n s i o n a l infant s o l i d f o o d f e e d i n g m o d e l that links t h e fourth t h e m e 'gaining expertise' with t h e p r e v i o u s t h r e e t h e m e s ; f h e feeding process, perceiving infant food needs and ways of feeding. T h e fourth t h e m e i n c l u d e s 5 c o n c e p t s (finding a n d u s i n g r e s o u r c e s , f e e l i n g s c a r e d , b e i n g a first t i m e m o t h e r , s e e k i n g r e a s s u r a n c e a n d l e a r n i n g t h r o u g h trial a n d error).  91  '  f  J  RESULTS 4.6.1. Finding and using resources  T h e m o t h e r s u s e d information f r o m n u m e r o u s r e s o u r c e s , print a s well a s f r o m v e r b a l s o u r c e s , to g u i d e their d e c i s i o n s with r e g a r d s to infant s o l i d f o o d f e e d i n g . T h e three m a i n print r e s o u r c e s u s e d b y t h e s e m o t h e r s w e r e the p o p u l a r p r e s s s u c h a s b o o k s , m a g a z i n e s , a n d r e c i p e books, professional guidelines a n d charts, and/or pamphlets prepared by baby food c o m p a n i e s a n d infant f e e d i n g information o n f o o d p a c k a g i n g . T h e v e r b a l r e s o u r c e s that w e r e u s e d w e r e either f r o m the p r o f e s s i o n a l s e c t o r (public health n u r s e s , nutritionists, d o c t o r s , a n d c o m m u n i t y g r o u p s , parent g r o u p s a n d t h e nutrition hotline), o r t h e m o t h e r ' s s o c i a l network (family, f r i e n d s , a n d m o t h e r s ' g r o u p s ) . O f the m a n y r e s o u r c e s c i t e d , n o m o t h e r c o m m e n t e d that information f r o m the t e l e v i s i o n o r radio h a d i n f l u e n c e d their f e e d i n g p r a c t i c e s . A s u m m a r y of the r e s o u r c e s u s e d b y the participants is p r o v i d e d in T a b l e 3.  Table 3. Resources used by study participants V E R B A L Sources  PRINT/PAPER Sources Popular Press  Professional  1. books (baby)  1. public health nurses  2. magazines  2.  3. recipe books  nutritionists  3. doctors 4. community groups  Professional  4.  5. parent groups  handouts of infant feeding  6. nutrition hotlines  guidelines and charts Social Network Commercial  1. family  5. pamphlets (prepared by  2. friends  infant food companies)  3. mothers' groups  6. food packaging (including  4. other experienced mothers  infant feeding information)  92  RESULTS T h e f o l l o w i n g q u o t e s g i v e a n e x a m p l e of the n u m e r o u s r e s o u r c e s m o t h e r s u s e d in this s t u d y a s w e l l a s w h a t t h e y f o u n d u s e f u l . In t h e first q u o t e , the m o t h e r d e s c r i b e s t h e i m p o r t a n c e of u s i n g a c o m b i n a t i o n of r e s o u r c e s . T h i s m o t h e r s u g g e s t e d that 3 r e s o u r c e s c o m b i n e d w e r e important, c o m m u n i t y n u r s e s , friends a n d r e a d i n g . T h e s e c o n d mother, a s in later q u o t e s , e x p r e s s e d c o n c e r n a b o u t h a v i n g to d o s o m u c h g u e s s i n g a n d that it w a s difficult to find information. In a d d i t i o n to t h e s e c o n c e r n s , the m o t h e r reflected o n the reality of b e i n g a 'first t i m e m o m ' a n d b e i n g i n e x p e r i e n c e d with f e e d i n g b a b i e s .  "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 (9899)... Pamphlets...Baby Food Companies Send You... "What to Expect in the First Year" (9935)... 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  RESULTS 4.6.2. Being a first time mother and feeling scared T h e m o t h e r s in this s t u d y a p p e a r e d to b e m o v i n g t h r o u g h a l e a r n i n g p r o c e s s f r o m b e i n g a 'first time mother" w h o m a y b e i n e x p e r i e n c e d f e e d i n g her infant s o l i d f o o d s to b e c o m i n g e x p e r i e n c e d . F i v e m o t h e r s w h o d e s c r i b e d t h e m s e l v e s a s 'first time' m o t h e r s u s e d the following e x p r e s s i o n s to reflect their infant f e e d i n g c o n c e r n s , " Y o u just don't k n o w if y o u a r e d o i n g it right", " E v e r y t h i n g is n e w " , " I f e e l like I don't k n o w a t h i n g " , " Y o u ' r e not really s u r e w h a t to d o " , "It's like g o i n g into s o m e t h i n g b l i n d ' , " C o n f u s i n g . . . I totally f e e l like I don't k n o w w h a t I'm d o i n g " , " It's just s o difficult', a n d " I a m u n s u r e . . . " . 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 n e x p e r i e n c e a n d p o s s i b l y a l a c k of c o n f i d e n c e p o s s i b l y d u e to t h e a b s e n c e of critical e x p e r i e n c e that is n e e d e d to u n d e r s t a n d h o w to f e e d s o l i d f o o d s during t h e transition p r o c e s s . T h e following q u o t e s d e s c r i b e c o m m o n f e e l i n g s a b o u t b e i n g a 'first time' mother.  Further, t h e third q u o t e s u g g e s t s that this  m o t h e r ' s i n e x p e r i e n c e m a y h a v e i n c r e a s e d her level of a p p r e h e n s i o n , s u c h a s f e e l i n g s c a r e d a b o u t the infant f e e d i n g p r o c e s s itself. " F e e l i n g s c a r e d " w a s a c o n c e r n reported by s e v e r a 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  RESULTS 4.6.3. Seeking reassurance T h e m o t h e r s in this s t u d y d e s c r i b e d t h e i m p o r t a n c e of f e e l i n g ' r e a s s u r e d ' f r o m e x t e r n a l s o u r c e s a b o u t h o w t h e y w e r e f e e d i n g their infants. T h e following q u o t e s illustrate h o w the m o t h e r s u s e d different r e s o u r c e s for ' r e a s s u r a n c e ' . T h e s e m o t h e r s a p p e a r e d to b e s e e k i n g s p e c i f i c information, p o s s i b l y in o r d e r to p r o v i d e s u p p o r t a n d r e a s s u r a n c e . T h e information a p p e a r e d to b e important b e c a u s e it p r o v i d e d r e a s s u r a n c e that t h e y w e r e ' o n track' with 'what t h e y w e r e s u p p o s e to b e d o i n g ' , f e e d i n g their infant. Further, a l t h o u g h the m o t h e r s u s e d print r e s o u r c e s t h e y s e e m e d to s e e k , in particular, v e r b a l r e a s s u r a n c e f r o m health c a r e e x p e r t s .  "[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 m o t h e r s c o m m e n t e d o n the a d v i c e that t h e y r e c e i v e d f r o m different s o u r c e s . In particular, l e a r n i n g f r o m other m o t h e r s , e s p e c i a l l y ' e x p e r i e n c e d ' m o t h e r s a p p e a r e d to b e e x t r e m e l y u s e f u l . T h e s e m o t h e r s s e e m e d to b e s a y i n g that the a d v i c e t h e y r e c e i v e d or s o u g h t f r o m other m o t h e r s w a s particularly u s e f u l b e c a u s e it w a s p r a c t i c a l . T h e following q u o t e s a l s o s u g g e s t that t h e first t i m e m o t h e r ' s s o c i a l n e t w o r k m a y b e v e r y important s i n c e it m a y p r o v i d e the  95  RESULTS n e e d e d o p p o r t u n i t i e s for e x p e r i e n t i a l l e a r n i n g , in o r d e r to d i s c u s s e x p e r i e n c e s a n d thus ' g a i n s o l i d f o o d f e e d i n g e x p e r t i s e ' . T h e following m o t h e r u s e d a c o m b i n a t i o n of r e s o u r c e s , o n e of w h i c h w a s a n ' e x p e r i e n c e d ' m o t h e r of 4 c h i l d r e n . T h i s m o t h e r , a s d i d o t h e r s m o t h e r s , ' r e c e i v e d ' information f r o m b a b y f o o d c o m p a n i e s o r public health g u i d e l i n e s but a l s o ' s o u g h t ' information for her s p e c i f i c needs.  "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 m o t h e r s in this s t u d y h a d s o u g h t a d v i c e (print a n d verbal) f r o m health p r o f e s s i o n a l s . In t h e first q u o t e , t h e m o t h e r s o u g h t 'expert' a d v i c e f r o m health p r o f e s s i o n a l s , both in print a n d v e r b a l f o r m a n d h a d a s k e d q u e s t i o n s , h o w e v e r , t h e q u o t e s u g g e s t s that this m o t h e r w a s still u n s u r e a b o u t h o w to f e e d h e r infant, e s p e c i a l l y with r e g a r d s to m e a t . T h e q u o t e a l s o reflects the m o t h e r ' s i n e x p e r i e n c e a n d that s h e w a s trying to figure out h o w to f e e d h e r infant s o l i d s t h r o u g h u s i n g h e r print r e s o u r c e s a n d h e r d o c t o r . P o s s i b l y , w h a t this m o t h e r 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 practical infant f e e d i n g i n f o r m a t i o n , information w h i c h d o e s not a p p e a r to b e p r o v i d e d f r o m t h e r e s o u r c e s that s h e h a d u s e d .  96  RESULTS "/ 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 critique of t h e c o n t e n t of t h e i n f o r m a t i o n r e c e i v e d b y 'expert' s o u r c e s is d e s c r i b e d in t h e first q u o t e . T h e t e r m 'they refers to h e a l t h p r o f e s s i o n a l s . T h e m o t h e r c o m m e n t s not o n l y o n 1  w h a t 'they g i v e y o u ' , s u c h a s starting, s l o w p r o g r e s s i o n , a n d g o a l s b y o n e y e a r but a l s o w h a t 'they don't "tell y o u " , s u c h a s " h o w to get t h e r e " . T h e m o t h e r s in this s t u d y c i t e d t h e n e e d for 1  m o r e ' s p e c i f i c i n f o r m a t i o n ' a n d u s e d p h r a s e s s u c h a s " g o with y o u r i n s t i n c t s . . . l i s t e n to y o u r baby" a n d " s o m u c h information ... c o n t r a d i c t i n g . . . g o with h o w y o u f e e f to e x p r e s s their e x p e r i e n c e s . T h e s e p h r a s e s s u g g e s t the m o t h e r is ' g a i n i n g e x p e r t i s e ' a n d p o s s i b l y c o n f i d e n c e s i n c e s h e a p p e a r s to h a v e l e a r n e d h o w to trust h e r o w n j u d g e m e n t . H o w e v e r , the a v a i l a b l e d a t a a l s o s u g g e s t that t h e r e a r e g a p s in t h e s o l i d f o o d f e e d i n g information p r o v i d e d f o r t h e s e m o t h e r s .  "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  RESULTS 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 L e a r n i n g to f e e d s o l i d f o o d s w a s e x p r e s s e d b y the m o t h e r s in this s t u d y a s a p r o c e s s that took p l a c e o v e r t i m e . In g e n e r a l , all of the m o t h e r s a p p e a r e d to h a v e g a i n e d e x p e r i e n c e o n h o w t h e y f e d s o l i d f o o d s t h r o u g h 'trial a n d error . T h e first q u o t e illustrates a m o t h e r w h o a p p e a r e d to 1  b e i n e x p e r i e n c e d a n d u n c e r t a i n a b o u t w h a t to d o a n d t h u s m a y h a v e b e e n l a c k i n g f e e d i n g c o n f i d e n c e . T h e s e e x p e r i e n c e s m a y h a v e c r e a t e d a h i g h level of frustration for this m o t h e r .  The  s e c o n d q u o t e illustrates a m o t h e r that h a d b e e n f e e d i n g s o l i d f o o d s to her infant for s o m e t i m e a n d a p p e a r e d to b e ' g a i n i n g e x p e r t i s e ' . T h e m o t h e r s t a t e s it is " f u n f e e d i n g him n o w " . T h i s s t a t e m e n t s u g g e s t s that s h e h a s m o v e d a l o n g a l e a r n i n g ' c u r v e ' , a t e r m c o i n e d in t h e first q u o t e , a n d h a s ' g a i n e d e x p e r t i s e ' . Interestingly, the s a m e p h r a s e s u g g e s t s s h e m a y h a v e e x p e r i e n c e d a period of t i m e w h e n it w a s not a s " f u n f e e d i n g " h e r 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] (10532-560)... 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 (7836)... [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 e x p e r i e n c e of b e i n g a 'first t i m e mother w a s a c o m m o n t h e m e d e s c r i b e d b y the 5  m o t h e r s in this s t u d y . T h e m o t h e r s d e s c r i b e d t h e e x p e r i e n c e of learning to f e e d their infants. T h e m o t h e r s a p p e a r e d to b e m o v i n g a l o n g a l e a r n i n g ' c u r v e ' f r o m b e i n g i n e x p e r i e n c e d to b e c o m i n g e x p e r i e n c e d f e e d i n g their infants s o l i d f o o d s . T h e learning p r o c e s s a p p e a r e d to c o i n c i d e with t h e m o t h e r ' s level of certainty a b o u t 'how* to f e e d h e r infant a n d trust in h e r o w n judgement.  M a n y of t h e m o t h e r s s t a t e d that r e a s s u r a n c e w a s important to t h e m .  Reassurance  f r o m health c a r e p r o f e s s i o n a l s a p p e a r e d to b e u s e f u l to m o t h e r s b e c a u s e it s e e m e d to h e l p t h e m 'tailor their f e e d i n g s t r a t e g i e s a c c o r d i n g to t h e r e s p o n s e s t h e y r e c e i v e d . Interestingly, a l t h o u g h 1  the m o t h e r s r e c e i v e d a n d s o u g h t information f r o m multiple r e s o u r c e s , p r a c t i c a l information f r o m ' e x p e r i e n c e d ' m o t h e r s , a p p e a r e d to a l s o b e highly v a l u e d . It s e e m s p o s s i b l e that the c o n c e p t s d e s c r i b e d in this s e c t i o n (finding/using r e s o u r c e s , b e i n g a first t i m e m o t h e r a n d f e e l i n g s c a r e d , s e e k i n g r e a s s u r a n c e a n d l e a r n i n g t h o u g h trial a n d error) i n f l u e n c e d the m o t h e r s ' ' l e a r n i n g c u r v e ' a n d t h u s if, o r h o w q u i c k l y t h e m o t h e r g a i n e d h e r infant s o l i d f o o d f e e d i n g ' e x p e r t i s e ' d u r i n g the liquid to s o l i d f o o d transition p r o c e s s . T h e t y p e of r e s o u r c e s u s e d (i.e., print v e r s u s verbal) a n d the s o u r c e of t h e r e s o u r c e (i.e., p r o f e s s i o n v e r s u s s o c i a l networks) a p p e a r e d to i n f l u e n c e the m o t h e r ' s infant s o l i d f o o d f e e d i n g d e c i s i o n s . Further, t h e m o t h e r s a p p e a r e d to n e e d information r e s o u r c e s at s p e c i f i c s t a g e s of the f e e d i n g p r o c e s s to m e e t their u n i q u e individual situation (e.g., f o o d r e f u s a l , s l o w w e i g h t g a i n , texture difficulties, etc.). T h e a v a i l a b l e d a t a c l e a r l y s u g g e s t that the m o t h e r ' s s o l i d f o o d f e e d i n g 'capability" w a s d e t e r m i n e d , to s o m e d e g r e e , b y h e r 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 theme  tailoring the transition process  is illustrated in F i g u r e 15 a s ' c e n t r a l ' to the solid f o o d  f e e d i n g 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 l a u s i b l e r e l a t i o n s h i p s a m o n g t h e 5 t h e m e s w e r e identified, d e s c r i b e d a n d d e v e l o p e d u s i n g t h e p r o c e d u r e s outlined by 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 ( G l a s e r , 1 9 7 8 ) . T h e s e p r o c e d u r e s h a v e b e e n d e s c r i b e d in t h e d e s i g n a n d methods section. T h e core theme themes  tailoring the transition process  w a s linked to the other 4  (the feeding process, perceiving infant food needs, ways of feeding a n d gaining  expertise), t h u s  fulfilling its p r i m e function of integrating theory.  102  RESULTS  Context The feeding process 1. 2. 3.  The mother starting the feeding process and offering solid food Sporadic versus routine cereal feeding The reasons for introducing solids (advice, readiness, sleep) and food selection (food acceptance and allergy risk)  Conditions 1. 2. 3.  Causal Conditions Mother factors: Perceptions of infant food needs 1. Readiness (allergies) 2. Food preferences 3. Hunger  Type/brand of solid food Infant age Environment (work, infant feeding information and resources)  t Tailoring the transition process  Food acceptance/ rejection responses to the solid food or feeding  Covariance -The individual variation and differences between mothers' ^diversity  .  solid food acceptance  :.  Infant factors:  I  Consequences Dietary Adequacy  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 feedin  expertise, tailoring the transition process and dietary adequacy.  103  RESULTS T h e c o r e t h e m e h a s p r a c t i c a l r e l e v a n c e to t h e d a y to d a y c o n t e x t of infant f e e d i n g b e c a u s e it i n c r e a s e s o u r u n d e r s t a n d i n g of not o n l y h o w infants c o u l d b e f e d s o l i d f o o d s o v e r t i m e , but a l s o w h y t h e r e a r e v a r i a t i o n s a m o n g infant's dietary c o n s u m p t i o n p a t t e r n s . A s F i g u r e 15 illustrates, m a n y c o n d i t i o n s (i.e., t h e t y p e of s o l i d f o o d s offered, t h e infant's a g e a n d t h e e n v i r o n m e n t ( e . g . , w o r k s c h e d u l e s , a v a i l a b l e r e s o u r c e s ) within t h e infant f e e d i n g context, e a s i l y i n f l u e n c e t h e c o r e t h e m e , t h u s m a k i n g the t h e m e highly v a r i a b l e . C o n s e q u e n t l y , the c o r e t h e m e c a n b e e x a m i n e d a l o n g a d i m e n s i o n f r o m t h e m o t h e r 'tailoring', to the m o t h e r not 'tailoring' the solid f o o d transition p r o c e s s , in r e s p o n s e to h e r p e r c e p t i o n s of h e r infant's f o o d c u e s a n d r e s p o n s e s . T h u s , the r a n g e of b e h a v i o r s that t h e m o t h e r s u s e , or d o not u s e , to f e e d their infants, r e p r e s e n t s the ' d i m e n s i o n s ' of the fifth t h e m e - tailoring the transition process. T h e first t h e m e - fhe feeding process, identifies t h e potential r e l a t i o n s h i p b e t w e e n t h e m o t h e r starting or offering s o l i d f o o d s a n d t h e infant's r e s p o n s e to w h a t is offered (i.e., a c c e p t i n g o r rejecting the f o o d ) . T h e interaction (action-reaction) b e t w e e n the mother-infant pair a n d f o o d is, therefore, the c e n t r a l f o c u s of the t h e m e 'the f e e d i n g p r o c e s s ' . T h e link b e t w e e n the first a n d the fifth t h e m e c a n b e further e x p l o r e d b y e m p h a s i z i n g the d i m e n s i o n a l a s p e c t of the c o n c e p t 'tailoring'. F o r e x a m p l e , if the m o t h e r offers s o l i d f o o d but the infant rejects the f o o d , the m o t h e r m a y t h e n tailor h e r f e e d i n g s t r a t e g y to try a n d g a i n a c c e p t a n c e , o r s h e m a y not tailor h e r s t r a t e g y a n d i n s t e a d c o n t i n u e to offer t h e s a m e f o o d in t h e s a m e w a y . T h u s , t h e c o n c e p t 'tailoring' r e p r e s e n t s t h e m o t h e r s ' ' w a y of a d a p t i n g o r not a d a p t i n g the type of s o l i d f o o d s a n d the f e e d i n g s t r a t e g y that s h e u s e d . T h e 'way* that the m o t h e r ' a d a p t s ' c a n b e c o n s i d e r e d d y n a m i c (tailored) o r static (not tailored) with r e g a r d s to p r o m o t i n g a c c e p t a n c e of s o l i d f o o d s , b y the infant. T h e first t h e m e - the feeding process p r o v i d e s t h e c o n t e x t within w h i c h the m a n y c o n d i t i o n s exist, that e a s i l y i n f l u e n c e if, o r h o w the m o t h e r 'tailors t h e transition p r o c e s s ' . C l e a r l y , f o o d a c c e p t a n c e or rejection b y the infant d u r i n g 'the f e e d i n g p r o c e s s ' is a p r i m a r y f a c t o r that potentially ' c a u s e s ' the m o t h e r to b e g i n 'tailoring' h e r infant f e e d i n g s t r a t e g y . T h e s e c o n d t h e m e - perceiving infant food needs identifies t h e potential relationship b e t w e e n the m o t h e r ' s p e r c e p t i o n s of h e r infant's f o o d n e e d s a n d their i n f l u e n c e o n h e r s u b s e q u e n t s o l i d f o o d f e e d i n g b e h a v i o r s . T h u s , this t h e m e is a l s o c o n s i d e r e d a s k e y in  104  RESULTS potentially c a u s i n g t h e m o t h e r to b e g i n 'tailoring t h e transition p r o c e s s ' . T h e m o t h e r ' s p e r c e p t i o n of 4 k e y f o o d c u e s a p p e a r e d to strongly i n f l u e n c e the m o t h e r s ' f e e d i n g d e c i s i o n s . T h e c u e s i n c l u d e d infant d e v e l o p m e n t a l r e a d i n e s s , f o o d t a s t e a n d texture p r e f e r e n c e s , h u n g e r a n d a l l e r g y risk. T h e link b e t w e e n the s e c o n d a n d t h e fifth t h e m e c a n b e further e x p l o r e d b y e m p h a s i z i n g the d i m e n s i o n a l a s p e c t of t h e c o n c e p t 'tailoring'. T h e m o t h e r s ' p e r c e p t i o n s of their infants' f o o d n e e d s a p p e a r e d to c l e a r l y i n f l u e n c e their s o l i d f o o d f e e d i n g strategies - '  tailoring'.  For example,  the m o t h e r w h o r e c o g n i z e d that the infant w a s not a c c e p t i n g the s o l i d f o o d b e c a u s e h e / s h e m a y not h a v e b e e n h u n g r y c o u l d 'tailor" h e r next s o l i d f o o d m e a l time a c c o r d i n g to h e r infant's h u n g e r c u e s s o that t h e f o o d m a y t h e n b e a c c e p t e d better b y the infant. T h e m o t h e r w h o r e c o g n i z e d that her infant w a s h u n g r y at s p e c i f i c t i m e s of t h e d a y c o u l d , therefore, r e s p o n d b y a d a p t i n g h e r f e e d i n g s c h e d u l e a c c o r d i n g to t h e s e c u e s . In this c o n t e x t , this m o t h e r a p p e a r e d to h a v e b e e n 'tailoring' h e r f e e d i n g s t r a t e g y b y linking h e r p e r c e p t i o n s of her infant's f o o d n e e d s (cues) to the infant f e e d i n g t e c h n i q u e s that s h e w a s u s i n g , in o r d e r to r e s p o n d a c c o r d i n g l y . T h e m o t h e r s that did not p e r c e i v e a n y infant f o o d c u e s (e.g., h u n g e r c u e s ) , or misinterpreted f o o d c u e s (e.g., f o o d p r e f e r e n c e s ) , m a y not h a v e b e e n a b l e to effectively 'tailor their f e e d i n g s t r a t e g i e s to m e e t their 1  infant's' f o o d n e e d s , in t h e s a m e w a y a s m o t h e r s w h o w e r e a b l e to r e c o g n i z e t h e s e c u e s . T h u s , the m o t h e r ' s p e r c e p t i o n s of h e r infant's f o o d n e e d s a p p e a r e d to b e a ' c a u s a l c o n d i t i o n ' influencing if, or h o w the m o t h e r 'tailored' h e r s o l i d f o o d f e e d i n g r e s p o n s e . T h e third t h e m e -  ways of feeding  illustrated in F i g u r e 15 identifies t h e potential  relationship b e t w e e n the m o t h e r ' s f e e d i n g s t r a t e g i e s a n d the infant's a c c e p t a n c e of s o l i d f o o d s (solid f o o d c o n s u m p t i o n ) . A w i d e r a n g e of infant f e e d i n g t e c h n i q u e s w a s d i s c o v e r e d f r o m the m o t h e r s ' d e s c r i p t i o n s of h o w t h e y f e d their infant d u r i n g the f e e d i n g p r o c e s s . S o m e of the f e e d i n g t e c h n i q u e s s e e m e d to b e better at p r o m o t i n g s o l i d f o o d a c c e p t a n c e t h a n o t h e r t e c h n i q u e s (i.e., m i x i n g a n d s w i t c h i n g c o m p a r e d to waiting or r e p e a t e d l y offering p r e v i o u s l y rejected f o o d s ) . T h e c o n c e p t ' a d a p t i n g ' is t h e k e y a s p e c t of the third t h e m e b e c a u s e , like 'tailoring', it e m p h a s i z e s that s o l i d f o o d f e e d i n g is a p r o c e s s o v e r time a n d that t h e m o t h e r ' s b e h a v i o r s a r e i n f l u e n c e d b y the rapidly c h a n g i n g c o n d i t i o n s within the s o l i d f o o d f e e d i n g context. H o w e v e r , t h e m o t h e r ' s ' w a y ' of f e e d i n g s o l i d f o o d s is a 'contingent' f a c t o r that a p p e a r s to directly  105  RESULTS affect the c o r e t h e m e . In o r d e r for the m o t h e r to 'tailor or 'adapt' her f e e d i n g b e h a v i o r s s h e m u s t 1  u s e a f e e d i n g strategy(s) o r t e c h n i q u e ( s ) . T h e r e f o r e , the m o t h e r ' s s o l i d f o o d f e e d i n g b e h a v i o r s a r e contingent or c o n d i t i o n a l to the individual s t r a t e g i e s or t e c h n i q u e s that s h e u s e s . T h e link b e t w e e n the third a n d t h e fifth t h e m e c a n b e further e x p l o r e d b y e m p h a s i z i n g the d i m e n s i o n a l a s p e c t of the c o n c e p t 'tailoring'. It s e e m s p o s s i b l e that t h e m o t h e r m a y c h o o s e to tailor h e r f e e d i n g s t r a t e g y by a d a p t i n g h e r f e e d i n g t e c h n i q u e ( s ) to p r o m o t e the c o n s u m p t i o n of the s o l i d f o o d s that s h e is offering d u r i n g t h e transition f r o m a n e x c l u s i v e liquid diet to a m i x e d liquid a n d s o l i d f o o d diet. F o r e x a m p l e , p o s i t i o n i n g t h e infant o n their b a c k to f e e d s o l i d s a p p e a r e d to b e effective for o n e m o t h e r w h e n s h e w a s first starting s o l i d f o o d s . S o c i a l i z i n g with the infant d u r i n g m e a l t i m e a n d a l l o w i n g the infant to h a v e s o m e control o v e r t h e f e e d i n g e x p e r i e n c e , or ' e n g a g i n g ' t h e infant while f e e d i n g a p p e a r e d to b e effective s t r a t e g i e s for other m o t h e r s . H o w e v e r , s o m e m o t h e r s m a y not h a v e r e c o g n i z e d a n y relationship b e t w e e n t h e f e e d i n g s t r a t e g y that t h e y w e r e u s i n g a n d the a m o u n t of s o l i d f o o d their infant c o n s u m e d . A s a result, t h e s e m o t h e r s m a y not 'tailor" their infant f e e d i n g t e c h n i q u e ( s ) . C o n s e q u e n t l y , the transition p r o c e s s for individual infants w a s highly v a r i a b l e a n d this variability m a y b e e x p l a i n e d , in part, b y if, o r h o w the individual m o t h e r s w e r e 'tailoring the transition p r o c e s s ' . T h e fourth t h e m e - gaining expertise illustrated in F i g u r e 15 identifies the potential relationship b e t w e e n the individual m o t h e r ' s l e a r n i n g to f e e d h e r infant a n d h e r c a p a b i l i t y to 'tailor the ' w a y s h e f e d h e r infant d u r i n g the transition p r o c e s s . F o r e x a m p l e , a 'first time', p o s s i b l y i n e x p e r i e n c e d m o t h e r , a p p e a r e d to p r o g r e s s a l o n g a ' l e a r n i n g curve" w h e r e s h e l e a r n e d to f e e d her infant s o l i d f o o d s . T h i s p r o c e s s a p p e a r e d , for s o m e m o t h e r s , to b e t h r o u g h trial a n d error e x p e r i e n c e s , a n d r e c e i v i n g o r s e e k i n g r e a s s u r a n c e f r o m the a v a i l a b l e infant f e e d i n g r e s o u r c e s that t h e y u s e d . T h e e x p e r i e n c e s that the m o t h e r e n c o u n t e r e d d u r i n g the f e e d i n g p r o c e s s a n d the r e s o u r c e s that s h e u s e d potentially p r o m o t e d h e r l e a r n i n g to b e c o m e a n e x p e r i e n c e d f e e d e r . T h e a v a i l a b l e d a t a s u g g e s t that s o m e of t h e r e s o u r c e s ( P r o f e s s i o n a l G u i d e l i n e s a n d c o m m e r c i a l p a m p h l e t s a n d f o o d p a c k a g i n g information) that w e r e a v a i l a b l e to t h e m o t h e r s , a p p e a r e d to f o c u s o n w h a t t y p e of s o l i d f o o d s to f e e d a n infant at s p e c i f i c a g e s . Interestingly, m o s t of the r e s o u r c e s u s e d b y t h e m o t h e r s , in this s t u d y , d i d not a p p e a r to f o c u s o n d e s c r i b i n g the p r a c t i c a l , d a y to d a y ,  106  1  RESULTS a s p e c t s of h o w to f e e d a n infant s o l i d f o o d s , during the transition p r o c e s s w h e n the infant is l e a r n i n g to a c c e p t a r a n g e of different s o l i d f o o d s . T h e link b e t w e e n t h e fourth a n d fifth t h e m e c a n a l s o b e further e x p l o r e d b y e m p h a s i z i n g the d i m e n s i o n a l a s p e c t of the c o n c e p t 'tailoring'. T h e m o t h e r c o u l d potentially 'tailor' her f e e d i n g s t r a t e g i e s a n d t e c h n i q u e s , h o w e v e r , her a c t u a l 'tailoring' capability a p p e a r e d to b e c l e a r l y i n f l u e n c e d b y her l e v e l of f e e d i n g ' e x p e r t i s e ' . F o r 'first time' m o t h e r s , it s e e m s p o s s i b l e that e a r l y o n in t h e f e e d i n g p r o c e s s , w h e n t h e m o t h e r first i n t r o d u c e s s o l i d f o o d s , the m o t h e r m a y b e i n e x p e r i e n c e d a n d , t h e r e f o r e , l e s s s k i l l e d a n d c o n f i d e n t at 'tailoring' her f e e d i n g s t r a t e g i e s . T h e 'way that the m o t h e r 'tailors' her f e e d i n g t e c h n i q u e s m a y , therefore, b e l e s s r e s o u r c e f u l earlier 1  than later o n in the f e e d i n g p r o c e s s w h e n t h e m o t h e r h a s ' g a i n e d ' m o r e e x p e r i e n c e a n d h a s d e v e l o p e d m o r e f e e d i n g skills a n d c o n f i d e n c e . F o r e x a m p l e , the i n e x p e r i e n c e d m o t h e r , e a r l y in the transition p r o c e s s , m a y not h a v e l e a r n e d yet w h e n in t h e d a y to f e e d her infant s o l i d f o o d s .  In  contrast, with t i m e a n d e x p e r i e n c e the m o t h e r m a y learn w h e n in the d a y the infant is m o s t h u n g r y a n d t h e n 'tailor' her f e e d i n g s t r a t e g y b y a d j u s t i n g her f e e d i n g s c h e d u l e to b e m o r e c l o s e l y a l i g n e d with w h e n , in the d a y , h e r infant is hungry. T h u s , it s e e m s clearly p o s s i b l e that t h e m o t h e r ' s c a p a b i l i t y to effectively 'tailor' her s o l i d f o o d f e e d i n g strategies during t h e transition p r o c e s s is related to h e r s o l i d f o o d f e e d i n g e x p e r i e n c e ( s ) a n d the level of ' e x p e r t i s e ' that s h e g a i n s o v e r t i m e . T h e c o n c e p t ' g a i n i n g ' , is a k e y a s p e c t of the fourth t h e m e b e c a u s e like 'tailoring' it e m p h a s i z e s that t h e m o t h e r ' s ability to l e a r n t o f e e d s o l i d f o o d s is a p r o c e s s o v e r t i m e . It a l s o s e e m s p o s s i b l e that t h e m o t h e r ' s level of f e e d i n g ' e x p e r t i s e ' (capability) a s well a s t h e s p e e d at w h i c h t h e m o t h e r ' g a i n s ' e x p e r t i s e i n f l u e n c e d h e r 'tailoring' strategies. B o t h f a c t o r s , t h e ' e x p e r t i s e ' itself a n d t h e s p e e d at w h i c h the ' e x p e r t i s e ' is g a i n e d , m a y e x p l a i n s o m e of t h e variability a m o n g the s o l i d f o o d c o n s u m p t i o n p a t t e r n s of the infants in this study. A s i n d i c a t e d in F i g u r e 14 t h e t h e m e ' g a i n i n g e x p e r t i s e ' w a s l a b e l e d a s a rapidly c h a n g i n g ' c o n d i t i o n ' within the s o l i d f o o d f e e d i n g context.  107  RESULTS  4.7.2. Dietary intake patterns T h e i m p o r t a n c e of d i e t a r y iron intake for the rapidly g r o w i n g infant d u r i n g t h e s e c o n d s i x m o n t h s of life is w e l l d o c u m e n t e d . T h e r e f o r e , the c o n s u m p t i o n of iron c o n t a i n i n g s o l i d f o o d s is of particularly interest, d u r i n g the liquid to s o l i d f o o d transition p r o c e s s that u s u a l l y o c c u r s b e t w e e n 4 - 9 m o n t h s of a g e . F o r that r e a s o n , the c e r e a l f e e d i n g p r a c t i c e s d u r i n g this p e r i o d w e r e identified. A l e g e n d w a s d e v e l o p e d f r o m the interview d a t a ( T a b l e 4) a n d w a s u s e d to identify a n d g r a p h i c a l l y r e p r e s e n t t h e s o u r c e s of s o l i d f o o d s that the m o t h e r s f e d their infants at different a g e s c o n s i s t e n t l y a c r o s s t h e p a r t i c i p a n t s . W h e r e p o s s i b l e , the quantity of s o l i d f o o d that w a s f e d a n d t h e f e e d i n g t e c h n i q u e s (i.e. 'offering' s i n g l e g r a i n c e r e a l s o r 'offering' c e r e a l m i x t u r e s etc.) that w e r e u s e d w e r e d e s c r i b e d . T h e 3 a r r o w s in t h e l e g e n d s h o w t h e a g e w h e n t h e m o t h e r f e d s i n g l e grain c e r e a l s , c e r e a l c o m b i n a t i o n s , o r fruits or v e g e t a b l e s . T h i r t e e n i t e m s a n d v a r i a t i o n s of f e e d i n g w e r e identified a n d a r e listed in t h e l e g e n d in T a b l e 4. S i x v a r i a t i o n s p e r t a i n i n g to iron fortified infant c e r e a l f e e d i n g w e r e d e s c r i b e d b y the m o t h e r s a n d i n c l u d e d in t h e l e g e n d ( n u m b e r s 1 t h r o u g h 6). T h e first pattern w a s l a b e l e d a s rice c e r e a l , to reflect the e x c l u s i v e f e e d i n g of infant rice c e r e a l (1). T h e s e c o n d pattern (2) refers to the f e e d i n g of a variety of o t h e r s i n g l e g r a i n c e r e a l s . T h e s o l i d a r r o w (  ^  ) w a s u s e d to  indicate that a m o t h e r a p p e a r e d to b e f e e d i n g s i n g l e g r a i n c e r e a l v a r i e t i e s o n l y at that a g e . T h e third pattern (3) reflects a m o t h e r ' s f e e d i n g with m i x e d grain c e r e a l s . T h e fourth pattern (4) r e p r e s e n t s s w i t c h i n g c o m m e r c i a l c e r e a l b r a n d s , s u c h a s f r o m H e i n z to G e r b e r . T h e fifth pattern (5) refers to the u s e of c o m m e r c i a l c e r e a l p r e m i x e d with fruits or v e g e t a b l e s . T h e last c e r e a l f e e d i n g pattern (6) r e p r e s e n t s ' m i x i n g ' c e r e a l s with fruits a n d / o r v e g e t a b l e s b y the mother. broken arrow ( — —  The  — • ) , illustrated in t h e l e g e n d w a s u s e d t o i n d i c a t e that a m o t h e r  a p p e a r e d to h a v e c h a n g e d f r o m f e e d i n g t h e s i n g l e g r a i n c e r e a l v a r i e t i e s to f e e d i n g m i x e d c e r e a l v a r i e t i e s a n d f o o d c o m b i n a t i o n m i x t u r e s , at the a g e i n d i c a t e d . F o u r v a r i a t i o n s of f e e d i n g fruit a n d v e g e t a b l e s w e r e identified f r o m the transcripts ( n u m b e r s 7 through 10); t h e s e w e r e s i n g l e fruits or v e g e t a b l e s , o r m i x e d fruits o r v e g e t a b l e s . S u b c a t e g o r i e s w e r e u s e d to i n d i c a t e if the fruit or v e g e t a b l e w a s p u r e e d (a) or m a s h e d (b).  108  RESULTS B r o k e n 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 C e r e a l s (Oat/Barley/Wheat...) 3 Mixed Grain C e r e a l s (Oat a n d Barley) 4 Switching Cereal B r a n d s (Heinz/Mead/Gerber...) 5 Grain Cereals (with a d d e d Fruit or Vegetables) 6 C e r e a l s (1/2/3/5) Mixed with fruits or vegetables 7 Single Fruits 8 Single V e g e t a b l e s 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, c h e e s e p i e c e s , c r a c k e r s , toast fruit p i e c e s a n d d (Dairy s n a c k s ; e.g. c h e e s e and/or yogurt)  Single Meats -v- Meats Mixed with Fruit or Vegetables (a1 h o m e m a d e ; a2 c o m m e r c i a l l y prepared; b trying to feed meat; c routinely feeding meat; d pureed; e c h u n k y )  The legend identifies the variety of solid foods in the transition graphs that the infants were fed at different ages.  Table 4.  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. T h e 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. A s 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 /2 months of age. Most of the mothers started with rice cereal and progressed from rice to other  1  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. A s 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 f e e d i n g p r a c t i c e s a l s o differed a m o n g the m o t h e r s with r e s p e c t to t h e quantity of c e r e a l c o n s u m e d . A t t h e t i m e of the interview with t h e m o t h e r , m o s t (10/12) of the infants b e t w e e n t h e a g e of 7 - < 9 m o n t h s c o n s u m e d a p p r o x i m a t e l y < 3 t a b l e s p o o n s to > 1 c u p of dry c e r e a l p e r d a y . T h e r e m a i n i n g 2 infants c o n s u m e d a b o u t 1/3 c u p dry - 1 c u p w e t c e r e a l p e r d a y , at 9 m o n t h s of a g e . W i t h i n 1 m o n t h after introducing c e r e a l s , m o s t of the m o t h e r s (7/12) i n t r o d u c e d either v e g e t a b l e s or fruit, or both to their infants. T h e r e m a i n i n g 5 m o t h e r s i n t r o d u c e d v e g e t a b l e s later ( b e t w e e n 1 a n d 4 m o n t h s after c e r e a l introduction). S i n g l e fruits o r v e g e t a b l e s w e r e f e d to the infants first, a n d t h e n a s t h e infant got o l d e r , s o m e m o t h e r s f e d m i x e d v a r i e t i e s . S e v e r a l m o t h e r s intentionally f e d alternating c o l o r s of fruits or v e g e t a b l e s ( e . g . g r e e n a n d o r a n g e ) , a s well a s a variety of different f r u i t / v e g e t a b l e s of the s a m e c o l o r (i.e. g r e e n b e a n s , p e a s , a n d s p i n a c h ) in o r d e r t o g i v e v a r i e t y in t h e diet. A s illustrated in t h e g r a p h s , o n l y 1, 9 m o n t h o l d infant, w a s f e d m e a t o n a 'routine' b a s i s ( g r a p h n u m b e r 5). S e v e n infants b e t w e e n 7 a n d 9 m o n t h s of a g e w e r e 'trying' m e a t s but their m o t h e r h a d not yet p r o g r e s s e d to 'routine' m e a t f e e d i n g . T h e r e m a i n i n g 4 infants, w h o w e r e b e t w e e n 7 a n d 8 m o n t h s of a g e , h a d not b e e n g i v e n a n y m e a t p r o d u c t s . F o r t h o s e w h o did f e e d m e a t , it w a s u s u a l l y f e d m i x e d in a c o m b i n a t i o n with a fruit or v e g e t a b l e (i.e. in a c o m b i n a t i o n of 1:4 m e a t with v e g e t a b l e s ) in o r d e r to i n c r e a s e acceptance. T h e t r a n s i t i o n g r a p h s w e r e s o r t e d into 3 g r o u p s a c c o r d i n g t o t h e a p p r o x i m a t e quantity of c e r e a l the infant c o n s u m e d . T h e 3 g r o u p s identified reflect low, m e d i u m a n d high c e r e a l c o n s u m p t i o n l e v e l s ( F i g u r e 17). A high c e r e a l c o n s u m p t i o n group (graph n u m b e r s 5, 8 a n d 9) w a s identified for 3 infants w h o w e r e 7 Vi, 8 Vz a n d 9 m o n t h s of a g e . T h e m o t h e r s reported that their infants c o n s u m e d a p p r o x i m a t e l y 1/3 c u p ( - 8 tbsp.) - 1 c u p of dry iron fortified infant c e r e a l p e r d a y , f r o m 6 m o n t h s of a g e to their p r e s e n t a g e . T h e transition g r a p h s of the ' h i g h ' c e r e a l c o n s u m p t i o n g r o u p of infants s u g g e s t s that the m o t h e r ' s s o l i d f o o d f e e d i n g s t r a t e g i e s / t e c h n i q u e s o v e r t i m e a p p e a r e d to p r o m o t e a c c e p t a n c e of a h i g h quantity of infant c e r e a l . F u r t h e r , a c c e p t a n c e of infant c e r e a l at a h i g h e r quantity c o n t i n u e d for a m u c h l o n g e r d u r a t i o n t h a n the other 2 g r o u p s ( m e d i u m a n d low c o n s u m p t i o n ) . T h e transition g r a p h s for this g r o u p of infants a p p e a r s c l e a r l y different f o r m the other 2 g r o u p s .  ill  RESULTS A m e d i u m c e r e a l c o n s u m p t i o n group (graph n u m b e r s 1, 2, 4, 6, 7 , 1 0 a n d 12) w a s identified for 7 of the infants w h o w e r e b e t w e e n 7 - 9 m o n t h s of a g e a n d reflects the c o n s u m p t i o n of a b o u t < 4 t a b l e s p o o n s of dry c e r e a l p e r d a y at 6 m o n t h s of a g e . F i v e of the infants in this g r o u p r e c e i v e d a p p r o x i m a t e l y 1/4 c u p ( - 5 t a b l e s p o o n s ) of dry c e r e a l p e r d a y b e t w e e n 7 - 8 m o n t h s of a g e . A l t h o u g h o n e infant ( g r a p h n u m b e r 1) c o n s u m e d a b o u t /2 c u p of dry c e r e a l p e r d a y at 7 1 / 2 1  m o n t h s of a g e , the a m o u n t c o n s u m e d at 6 m o n t h s w a s m o r e reflective of the m e d i u m c o n s u m p t i o n g r o u p t h a n t h e high c o n s u m p t i o n g r o u p . T h e d a t a a v a i l a b l e for o n e 9 - m o n t h - o l d infant ( n u m b e r 2) w a s limited b e t w e e n the 6 - 8 m o n t h p e r i o d a n d therefore the g r a p h i n d i c a t e s a q u e s t i o n m a r k for t h e quantity of c e r e a l c o n s u m e d d u r i n g that t i m e . H o w e v e r , the interview d a t a s u g g e s t that t h e e a r l i e r transition p r o c e s s w a s reflective of a s l o w e r a c c e p t a n c e c u r v e , c o m p a t i b l e with the m e d i u m rather t h a n the high c e r e a l c o n s u m p t i o n g r o u p . T w o m o t h e r s in t h e m e d i u m c e r e a l c o n s u m p t i o n g r o u p e x p r e s s e d c o n c e r n a b o u t their infant's weight g a i n ( g r a p h n u m b e r s 7 a n d 12). T h e c e r e a l c o n s u m p t i o n pattern in g r a p h 7 i n d i c a t e s that t h e infant w a s i n t r o d u c e d to s o l i d f o o d b e f o r e 4 m o n t h s of a g e a n d t h e n not 'routinely' f e d c e r e a l until 6 m o n t h s of a g e . T h i s infant a p p e a r e d to h a v e b e e n c o n s u m i n g a b o u t 4 t a b l e s p o o n s of dry c e r e a l p e r d a y b e t w e e n 6 a n d 7 m o n t h s of a g e . T h e m o t h e r ' s f e e d i n g strategy, s h o w n b y t h e s o l i d a r r o w , i n d i c a t e s that this m o t h e r u s e d o n l y t h e first of t h e s i x c e r e a l f e e d i n g v a r i a t i o n s listed o n t h e l e g e n d . T h i s infant w a s f o r m u l a f e d from 10 d a y s after birth. T h e c e r e a l c o n s u m p t i o n pattern in g r a p h 12 i n d i c a t e s that this infant w a s i n t r o d u c e d to s o l i d f o o d at a b o u t 4 m o n t h s of a g e , yet didn't a p p e a r to a c c e p t a l a r g e r quantity until a b o u t 6 m o n t h s of a g e . A c c e p t a n c e a p p e a r e d to i n c r e a s e w h e n the m o t h e r first s w i t c h e d c e r e a l b r a n d s at 5 m o n t h s , a n d s w i t c h e d to f e e d i n g p r e m i x e d c e r e a l s with a d d e d fruit or v e g e t a b l e s at 6 m o n t h s . T h e infant in g r a p h 12 w a s b r e a s t f e d e x c l u s i v e l y to 1 m o n t h of a g e a n d t h e n i n t r o d u c e d to 2-4 o u n c e s of f o r m u l a p e r d a y f r o m 1 - 7 m o n t h s of a g e . T h e a c c e p t a n c e of c e r e a l by infants in t h e m e d i u m c o n s u m p t i o n g r o u p a p p e a r e d to t a k e longer, in g e n e r a l , t h a n in t h e high c e r e a l c o n s u m p t i o n g r o u p , that is, the transition g r a p h s for this g r o u p of infants reflect t h e s l o w e r p a c e of infant c e r e a l a c c e p t a n c e . T h e transition pattern for this g r o u p of infants a l s o a p p e a r s c l e a r l y different f r o m t h e high a n d low c e r e a l c o n s u m p t i o n g r o u p s .  112  RESULTS A low c e r e a l c o n s u m p t i o n group w a s identified for 2 (graph n u m b e r s 3 a n d 11) infants w h o w e r e 7 a n d 8 m o n t h s of a g e . T h e low c e r e a l c o n s u m p t i o n pattern reflects the c o n s u m p t i o n of a p p r o x i m a t e l y 3 t a b l e s p o o n s or l e s s , of dry c e r e a l p e r d a y , from the a g e of introduction to t h e infant's p r e s e n t a g e . T h e transition g r a p h s of the 'low' c e r e a l c o n s u m p t i o n g r o u p s u g g e s t s that t h e s e m o t h e r s ' s o l i d f o o d f e e d i n g s t r a t e g i e s / t e c h n i q u e s o v e r t i m e a p p e a r e d to not p r o m o t e a c c e p t a n c e of infant c e r e a l w h e n the c e r e a l w a s i n t r o d u c e d at 4 a n d 5 m o n t h s , n o r throughout the next 3 m o n t h s . O n e m o t h e r a p p e a r e d to u s e s i n g l e grain c e r e a l s until a p p r o x i m a t e l y 6 m o n t h s a n d t h e n s w i t c h e d to c e r e a l s m i x e d with fruit o r v e g e t a b l e s (i.e. s h e u s e d 2 of t h e 6 c e r e a l variations listed in the l e g e n d ) . N e i t h e r s t r a t e g y i n c r e a s e d c e r e a l a c c e p t a n c e . H o w e v e r , at 7 m o n t h s , this infant r e c e i v e d 4 v a r i a t i o n s of t h e fruits a n d v e g e t a b l e s that a r e listed o n t h e l e g e n d a s n u m b e r s 7, 8, 9, a n d 1 0 . T h e infant w a s d e s c r i b e d a s readily a c c e p t i n g of t h e s e s o l i d f o o d s . T h e other m o t h e r in this g r o u p u s e d s i n g l e g r a i n c e r e a l s , other t h a n rice c e r e a l . T h e available d a t a are u n c l e a r a s to w h e t h e r or not s h e u s e d other c e r e a l feeding strategies listed in the l e g e n d . H o w e v e r , the infant a p p e a r e d to a c c e p t a g e n e r o u s a m o u n t of v e g e t a b l e s e a c h d a y by 5 m o n t h s of a g e . Interestingly, both of t h e s e mothers a p p e a r to b e feeding a larger quantity of fruits and/or v e g e t a b l e s than infant c e r e a l p e r day. T h e 7 m o n t h o l d infant (graph 3) w a s e x c l u s i v e l y b r e a s t - f e d until 6 m o n t h s , a n d t h e n s w i t c h e d to ' m i x e d ' f e e d i n g with low iron f o r m u l a . T h e o t h e r infant (graph 11) w a s e x c l u s i v e l y b r e a s t - f e d to 8 m o n t h s . T h e a v a i l a b l e d a t a s u g g e s t that t h e s e 2 infants m a y not h a v e a c c e p t e d a d e q u a t e quantities of iron c o n t a i n i n g c e r e a l s for a n a d e q u a t e duration. T h e m o t h e r s ' liquid (milk a n d f o r m u l a ) f e e d i n g p r a c t i c e s o v e r time w e r e a l s o identified b e c a u s e t h e milk f e e d i n g p r a c t i c e s m a y b e c l o s e l y linked to s u b s e q u e n t s o l i d f o o d f e e d i n g p r a c t i c e s d u r i n g t h e transition p r o c e s s . F o r e x a m p l e , the f r e q u e n c y a n d quantity of milk o r f o r m u l a f e d to t h e infant d u r i n g the d a y c o u l d i n f l u e n c e the quantity of s o l i d f o o d that t h e infant will a c c e p t d u e to satiety. In g e n e r a l , m o t h e r s p r o g r e s s e d f r o m e x c l u s i v e b r e a s t - f e e d i n g to m i x e d f e e d i n g ( f e e d i n g b o t h h u m a n milk a n d f o r m u l a ) , or f o r m u l a f e e d i n g . T h r e e e x c l u s i v e l y b r e a s t f e e d i n g m o t h e r s p r o g r e s s e d to e x c l u s i v e l y f e e d infant f o r m u l a . A s w o u l d b e e x p e c t e d , the liquid f e e d i n g p a t t e r n s v a r i e d with r e g a r d s to d u r a t i o n a m o n g t h e s t u d y participants.  113  RESULTS  F i g u r e 1 6 . T h e t y p e of milk f e d to 12 infants f r o m birth.  S i n c e the iron c o n t e n t of infant f o r m u l a s v a r i e s t h e t y p e of f o r m u l a u s e d w a s r e c o r d e d , w h e r e p o s s i b l e . A t birth, all of the infants w e r e b r e a s t - f e d . At t h e time of the interview, 4 m o t h e r s w e r e b r e a s t - f e e d i n g their infants of 7, 7 Vz, 8 a n d 9 m o n t h s of a g e without f e e d i n g a n y f o r m u l a . S i x m o t h e r s b r e a s t - f e d e x c l u s i v e l y for a s h o r t e r d u r a t i o n , a n d t h e n s w i t c h e d their infant to m i x e d b r e a s t a n d f o r m u l a f e e d i n g at <1, 2 , 4 o r 5 m o n t h s of a g e . O f t h e s e 6 m o t h e r s , 2 t h e n s w i t c h e d to e x c l u s i v e f o r m u l a f e e d i n g w h e n t h e infant w a s 6 M> a n d 7 m o n t h s of a g e . T w o m o t h e r s f e d f o r m u l a , starting at 1 0 d a y s a n d 1 m o n t h after birth. O n e m o t h e r in this s t u d y f e d low-iron f o r m u l a b e t w e e n 5 a n d 7 m o n t h s after e x c l u s i v e l y b r e a s t - f e e d i n g h e r infant to 4 m o n t h s of a g e . T h e o t h e r f o r m u l a f e e d i n g m o t h e r didn't s t a t e the iron c o n t e n t of t h e f o r m u l a . O f the 12 m o t h e r s in this s t u d y , 7 w e r e f e e d i n g v a r i o u s q u a n t i t i e s of iron fortified f o r m u l a to their infants.  114  RESULTS  4.8.  Questionnaire Results  F i v e q u e s t i o n s w e r e d e v e l o p e d in s e c t i o n A of the q u e s t i o n n a i r e to identify t h e m o t h e r s ' liquid f e e d i n g p r a c t i c e s ( S e c t i o n A ) . A l l of the m o t h e r s in this s t u d y b r e a s t f e d at birth. A t the time of the interview, 5/9 m o t h e r s w e r e still b r e a s t - f e e d i n g . M o s t m o t h e r s s t a t e d that they h a d r e p l a c e d or s u p p l e m e n t e d their b r e a s t milk f e e d i n g with infant f o r m u l a . Unfortunately, the q u e s t i o n c o u l d h a v e b e e n interpreted differently b y t h e m o t h e r s . M o t h e r s ' retrospective r e s p o n s e s c o u l d h a v e b e e n y e s to both s u p p l e m e n t a t i o n a n d r e p l a c e m e n t of b r e a s t - f e e d i n g with infant f o r m u l a . M o s t m o t h e r s (8/9) s t a t e d that b r e a s t - f e e d i n g w a s not s u p p l e m e n t e d o r r e p l a c e d with c o w , goat, or s o y - m i l k . O n e m o t h e r m i s u n d e r s t o o d c o w s ' milk for infant f o r m u l a . O f the 5 m o t h e r s b r e a s t - f e e d i n g their infant, 1 m o t h e r b r e a s t f e d o n c e p e r d a y , 1 m o t h e r 3 t i m e s p e r d a y , 1 m o t h e r 4 t i m e s p e r d a y , 1 m o t h e r 5 t i m e s p e r d a y , a n d the last m o t h e r b r e a s t f e d 8 t i m e s p e r d a y . O f the 7 m o t h e r s w h o r e p o r t e d giving infant f o r m u l a to their infant, o n l y 1 r e p o r t e d the f r e q u e n c y t h e y f e d their infant, w h i c h w a s 4 - 5 t i m e s p e r d a y . T h e m o t h e r s reported a r a n g e of f o r m u l a f e e d i n g p r a c t i c e s f r o m f e e d i n g 8 - 1 0 o u n c e s of f o r m u l a o n c e p e r w e e k to f e e d i n g 2 4 ounces per day. T h e d a t a o b t a i n e d f r o m t h e s e 5 q u e s t i o n s c a p t u r e d d a t a at o n e time point. T h e d a t a that w a s g a t h e r e d in t h e s p r e a d s h e e t format w a s m o r e c o m p r e h e n s i v e t h a n the s i n g l e r e s p o n s e format d e s c r i b e d a b o v e . T h e s p r e a d s h e e t w a s m o r e effective at o b t a i n i n g g r e a t e r detail, thus potentially giving a better u n d e r s t a n d i n g of the m o t h e r s ' liquid f e e d i n g p r a c t i c e s o v e r t i m e . T h r e e s p r e a d s h e e t s w e r e d e v e l o p e d for the q u e s t i o n n a i r e to identify t h e t y p e s , b r a n d s a n d a m o u n t s of liquids, c e r e a l s , a n d o t h e r s o l i d f o o d s that m o t h e r s f e d their infants o v e r t i m e . T h e intent of the first s p r e a d s h e e t in t h e q u e s t i o n n a i r e w a s to attempt to c a p t u r e liquid f e e d i n g p r a c t i c e s o v e r t i m e a n d identify h o w m o t h e r s ' liquid f e e d i n g p r a c t i c e s p r o g r e s s e d a s the infant a g e d . T h e d a t a f r o m the s p r e a d s h e e t format a p p e a r e d p r o m i s i n g b e c a u s e it w a s q u i c k , e a s y a n d p r o v i d e d d e t a i l o n w h a t t y p e a n d a m o u n t of milk w a s g i v e n at different a g e s . H o w e v e r , further r e v i s i o n s a r e n e e d e d in o r d e r to elicit c o n s i s t e n t d a t a ( f r e q u e n c y of f e e d s a n d the quantity). A l l of  115  RESULTS the m o t h e r s r e p o r t e d that t h e y b r e a s t f e d their infant in the h o s p i t a l . O n l y 4 m o t h e r s r e p o r t e d t h e f r e q u e n c y that t h e y b r e a s t f e d their infant o v e r t i m e . O n e m o t h e r started f e e d i n g 11 t i m e s p e r d a y a n d t h e n d e c r e a s e d f r e q u e n c y to 7 or 8 t i m e s p e r d a y at 4 m o n t h s . At 6 m o n t h s , the m o t h e r b r e a s t f e d h e r infant 6 t i m e s p e r d a y a n d t h e n d e c r e a s e d f r e q u e n c y to 4 or 5 t i m e s p e r d a y b y 7 m o n t h s . T w o other m o t h e r s f o l l o w e d s i m i l a r patterns of b r e a s t - f e e d i n g 8 t i m e s p e r d a y to a b o u t 4 m o n t h s a n d t h e n d e c r e a s e d f r e q u e n c y to 6 t i m e s p e r d a y at a b o u t 5 m o n t h s , a n d 3 t i m e s p e r d a y at 7 m o n t h s . In c ont r as t , 1 m o t h e r b r e a s t f e d h e r infant 8 t i m e s p e r d a y c o n s i s t e n t l y f r o m 1 to 7 m o n t h s . T h e m o t h e r s w h o f e d f o r m u l a did not report t h e f r e q u e n c y . F o u r m o t h e r s a l s o d i d not report t h e quantity of f o r m u l a t h e y u s e d . F o r t h e t w o m o t h e r s w h o r e p o r t e d t h e quantity of f o r m u l a t h e y u s e d , 1 m o t h e r f e d 1 1 2 5 milliliters p e r d a y f r o m 1 to 6 m o n t h s a n d t h e o t h e r f e d 7 5 0 milliliters p e r d a y to 7 m o n t h s of a g e . N o m o t h e r r e p o r t e d u s i n g c o w s ' milk (whole, 1 % , or s k i m ) , s o y - m i l k , o r g o a t s milk. F i v e m o t h e r s r e p o r t e d u s i n g iron-fortified f o r m u l a . E a c h m o t h e r u s e d infant f o r m u l a at different t i m e points that c o r r e s p o n d c l o s e l y to t h e m o t h e r s ' w e a n i n g p r a c t i c e s . O n e m o t h e r u s e d iron-fortified f o r m u l a for 1 m o n t h w h e n h e r infant w a s 6 m o n t h s of a g e . A n o t h e r m o t h e r u s e d this f o r m u l a for 2 m o n t h s w h e n h e r infant w a s 6 a n d 7 m o n t h s of a g e . T w o m o t h e r s r e p o r t e d u s i n g this f o r m u l a t y p e for 4 m o n t h s , o n e w h e n t h e infant w a s 5 to 8 m o n t h s , the other w h e n the infant w a s 6 to 9 m o n t h s of a g e , r e s p e c t i v e l y . T h e last m o t h e r r e p o r t e d u s i n g f o r m u l a for 7 m o n t h s w h e n h e r infant w a s 1 to 7 m o n t h s of a g e . F o u r m o t h e r s r e p o r t e d f e e d i n g low iron f o r m u l a . O n e m o t h e r f e d l o w iron fortified f o r m u l a for 1 m o n t h w h e n t h e infant w a s 1 m o n t h o l d . T w o m o t h e r s f e d this f o r m u l a for 2 m o n t h s . O n e w h e n the infant w a s 3 a n d 4 m o n t h s of a g e a n d the o t h e r w h e n t h e infant w a s 2 a n d 3 m o n t h s of a g e . Interestingly, o n e m o t h e r started f e e d i n g low iron f o r m u l a at 8 m o n t h s after s w i t c h i n g f r o m iron fortified f o r m u l a . J u i c e w a s i n t r o d u c e d a n d f e d to 1 infant at 4 m o n t h s , 2 infants at 5 m o n t h s , 4 infants at 6 m o n t h s a n d 3 infants at 7 m o n t h s of a g e , r e s p e c t i v e l y . T w e l v e q u e s t i o n s w e r e d e v e l o p e d in s e c t i o n B of t h e q u e s t i o n n a i r e to identify m o t h e r s ' iron fortified infant c e r e a l f e e d i n g p r a c t i c e s in o r d e r to u n d e r s t a n d better h o w t h e s e p r a c t i c e s o v e r t i m e m a y potentially i n f l u e n c e infant iron s t a t u s . A l l m o t h e r s s t a t e d that their infant ate c e r e a l .  116  RESULTS W h e n first starting infant c e r e a l m a n y m o t h e r s (5/9) u s e d b r e a s t milk to p r e p a r e the c e r e a l . O n e third of m o t h e r s u s e d f o r m u l a a n d o n l y o n e m o t h e r u s e d w a t e r to p r e p a r e the c e r e a l w h e n t h e y first started to mix liquids with t h e infant c e r e a l . H o w e v e r , at the t i m e of the interview, 5 m o t h e r s w e r e u s i n g f o r m u l a , 3 m o t h e r s w e r e u s i n g w a t e r a n d a f e w w e r e u s i n g juice or yogurt. Interestingly, o n e m o t h e r u s e d 4 different c e r e a l p r e p a r a t i o n m e t h o d s . M o s t of the m o t h e r s (8/9) s t a t e d that their infants ate all t h e c e r e a l that w a s p r e p a r e d . M a n y m o t h e r s (5/9) s t a t e d t h e y ' a l m o s t a l w a y s ' p r e p a r e d the s a m e quantity of c e r e a l e a c h t i m e they f e d their infants. A f e w m o t h e r s (2/9) s t a t e d that t h e y ' s o m e t i m e s ' p r e p a r e d the s a m e quantity e a c h time t h e y f e d their infant.  Interestingly, m a n y m o t h e r s (5/9) s t a t e d that t h e y ' a l w a y s ' , ' a l m o s t a l w a y s ' or ' s o m e t i m e s '  p r e p a r e d m o r e c e r e a l if their infant w a s h u n g r y . M a n y m o t h e r s (7/9) stated that they d i d not s a v e u n e a t e n c e r e a l . T w o t h i r d s of t h e m o t h e r s s t a t e d that t h e y ' a l w a y s ' or ' a l m o s t a l w a y s ' p r e p a r e d the b a b y ' s f o o d . T h e p e r s o n , o t h e r t h a n t h e m o t h e r , c i t e d a s ' s o m e t i m e s ' f e e d i n g t h e infant w a s the father, or t h e n a n n y or babysitter. Q u e s t i o n s B 8 to B11 w e r e d e v e l o p e d to identify h o w c l o s e l y c e r e a l w a s f e d to other liquid f o o d s s u c h a s b r e a s t milk in o r d e r to identify ' c o m p l e x f o o d m i x t u r e s ' that infants w e r e f e d . Iron bioavailability is k n o w n to differ d e p e n d i n g o n t h e t y p e of f o o d s that a r e c o m b i n e d together.  Most  of the m o t h e r s (5/9) s t a t e d that t h e y f e d c e r e a l s ' a l w a y s ' , ' a l m o s t a l w a y s ' , or ' s o m e t i m e s ' twice p e r d a y . A l m o s t half t h e m o t h e r s (4/9) s t a t e d that t h e y ' a l w a y s ' o r ' a l m o s t a l w a y s ' f e d c e r e a l o n c e p e r d a y . A f e w m o t h e r s (2/9) f e d c e r e a l t h r e e t i m e s p e r d a y . A l l of the m o t h e r s s t a t e d that t h e y ' a l w a y s ' f e d c e r e a l e v e r y d a y of t h e w e e k . T h e m o t h e r s s t a t e d that t h e y f e d c e r e a l either at f a m i l y m e a l t i m e s (4/9), m o r n i n g s o n l y (3/9), e v e n i n g s o n l y (2/9), b e t w e e n family m e a l s (1/9), or at a n o t h e r time (lunch) (1/9). Q u e s t i o n s 8, 9, a n d 11 c o u l d b e c o m b i n e d a n d a s k e d o n a d i a g r a m of a 2 4 h o u r c l o c k , in o r d e r to elicit m o r e a c c u r a t e d a t a o n timing b e t w e e n f e e d i n g the v a r i o u s s o l i d a n d liquid f o o d s . T h e last q u e s t i o n w a s a n o p e n - e n d e d q u e s t i o n that a s k e d a b o u t what i n f l u e n c e d h o w m u c h c e r e a l the b a b y e a t s . T h e r e s p o n s e c o u l d h a v e b e e n a n s w e r e d in relation to the m o t h e r s ' p e r c e p t i o n s at the p r e s e n t t i m e , or in g e n e r a l o v e r t h e last f e w m o n t h s . M o s t of the m o t h e r s (5/9) r e s p o n d e d that t h e y felt that h u n g e r w a s a d e t e r m i n a n t of c e r e a l c o n s u m p t i o n . S o m e m o t h e r s  117  RESULTS r e s p o n d e d that infant t i r e d n e s s (3/9) a n d f a m i l y interaction o r attention (3/9) w a s important. T e e t h i n g (1/9), l o c a t i o n of f e e d i n g (1/9), a n d activity l e v e l d u r i n g the d a y (1/9) w e r e a l s o c i t e d b y different m o t h e r s a s f a c t o r s important to the a m o u n t of c e r e a l their infant c o n s u m e d . T h e m o t h e r s ' timing of c e r e a l f e e d i n g (i.e. w h e n t h e infant is h u n g r y a n d not tired) a s well a s t h e interaction a r o u n d t h e m e a l t i m e itself a p p e a r e d to b e the k e y f a c t o r s cited a s important to c e r e a l c o n s u m p t i o n . T h e s e f a c t o r s w e r e a l s o f o u n d to b e important f r o m the interview d a t a a n a l y s i s . T h e d a t a o b t a i n e d f r o m the 12 s i n g l e r e s p o n s e q u e s t i o n s in this s e c t i o n c a p t u r e d d a t a , a g a i n , m o s t l y at o n e t i m e point. T h e s p r e a d s h e e t f o r m a t s e e m e d m o r e effective in o b t a i n i n g g r e a t e r d e t a i l , a n d t h u s potentially a better u n d e r s t a n d i n g of t h e m o t h e r s ' c e r e a l f e e d i n g p r a c t i c e s (type a n d b r a n d s ) o v e r t i m e . T h e d a t a that w e r e g a t h e r e d both in t h e s p r e a d s h e e t f o r m a t a n d t h e q u e s t i o n f o r m a t , n e v e r t h e l e s s , p r o v i d e d important i n f o r m a t i o n . H o w e v e r , i m p r o v e m e n t s c o u l d b e m a d e b y u s i n g a n h o u r l y c l o c k f or m at to obtain d a t a o n w h e n in t h e d a y infants a r e f e d v a r i o u s foods. T h e intent of t h e s e c o n d s p r e a d s h e e t in t h e q u e s t i o n n a i r e w a s to attempt to c a p t u r e c e r e a l f e e d i n g p r a c t i c e s o v e r t i m e a n d identify h o w p r a c t i c e s p r o g r e s s e d a s the infant a g e d . S e v e n m o t h e r s r e s p o n d e d to the q u e s t i o n o n w h a t t h e y m i x e d their c e r e a l with. All of t h e m o t h e r s , w h o r e s p o n d e d to t h e q u e s t i o n (6/6), h a d m i x e d c e r e a l with f o r m u l a . S i m i l a r to t h e s i n g l e r e s p o n s e d a t a , m o s t m o t h e r s (5/6) u s e d b r e a s t m i l k , a n d half of the m o t h e r s u s e d w a t e r . O n e m o t h e r u s e d b o t h j u i c e a n d yogurt. O n e m o t h e r u s e d five different liquids to mix c e r e a l with ( b r e a s t milk, f o r m u l a , w a t e r , j u i c e , a n d yogurt). T h e s p r e a d s h e e t format c a p t u r e d the different m i x i n g patterns o v e r t i m e . Interestingly, of t h e 5 m o t h e r s w h o u s e d b r e a s t milk to mix c e r e a l with, 2 u s e d it for 1 m o n t h e a c h , a n d 3 u s e d it for 3 m o n t h s . M o s t of t h e m o t h e r s (5/7) p r o g r e s s e d to m i x i n g c e r e a l with infant f o r m u l a after h a v i n g first m i x e d the c e r e a l with b r e a s t milk. T h e s p r e a d s h e e t s illustrate t h e t y p e a n d b r a n d of c e r e a l s the m o t h e r s u s e d . M a n y m o t h e r s (5/9) s w i t c h e d b e t w e e n 2 different b r a n d s . S o m e m o t h e r s (3/9) s w i t c h e d b e t w e e n 3 b r a n d s a n d o n l y 1 m o t h e r u s e d o n l y o n e b r a n d . In a d d i t i o n , m o t h e r s reported u s i n g b e t w e e n 1 to 5 different t y p e s of c e r e a l . O n e m o t h e r u s e d 1 t y p e , 3 m o t h e r s u s e d 2 t y p e s , 3 m o t h e r s u s e d 3  118  RESULTS t y p e s , a n d 1 m o t h e r e a c h u s e d 4 a n d 5 different t y p e s of c e r e a l s . N o m o t h e r s interviewed u s e d t o d d l e r or other c e r e a l s . M a n y m o t h e r s (5/9) u s e d 3 or m o r e t y p e s of c e r e a l . S e v e n q u e s t i o n s w e r e d e v e l o p e d in s e c t i o n C of t h e q u e s t i o n n a i r e to elicit d a t a o n t h e mothers' cereal purchasing decisions and practices. T h e s e questions were included b e c a u s e t h e y m a y reflect, to s o m e d e g r e e , the m o t h e r s ' c e r e a l f e e d i n g p r a c t i c e s . A l l of the m o t h e r s s t a t e d that t h e y ' u s u a l l y p u r c h a s e d t h e b a b y c e r e a l . O n l y o n e father w a s c i t e d a s p u r c h a s i n g c e r e a l s . 1  T h e m o t h e r s s t a t e d that t h e y either p u r c h a s e d infant c e r e a l at t h e g r o c e r y store (8/9) or the d r u g s t o r e (7/9). M o s t of t h e m o t h e r s s t a t e d c o n v e n i e n c e (7/9) a n d g o o d s e l e c t i o n (6/9) a s t h e m a i n r e a s o n s for p u r c h a s i n g c e r e a l s at t h e l o c a t i o n t h e y d i d . A l m o s t half of the m o t h e r s (4/9) s t a t e d that better p r i c e s w e r e a f a c t o r in t h e l o c a t i o n that t h e y s h o p p e d at for infant c e r e a l s . M a n y of the m o t h e r s (6/9) s a i d t h e y p u r c h a s e d c e r e a l a s part of a routine s h o p p i n g trip a n d m a d e s p e c i f i c trips to s p e c i f i c s t o r e s to p u r c h a s e c e r e a l s . O n e third of t h e m o t h e r s s a i d t h e y did not p u r c h a s e c e r e a l a s part of a routine s h o p p i n g trip nor m a d e s p e c i f i c trips to s p e c i f i c s t o r e s to p u r c h a s e c e r e a l s . Interestingly, m o s t of t h e m o t h e r s (7/9) s t a t e d that t h e y p u r c h a s e d o n l y 1 b o x of c e r e a l at a t i m e . S o m e of the m o t h e r s (4/9) p u r c h a s e d s e v e r a l b o x e s of different t y p e s a n d f e w e r m o t h e r s (2/9) s t a t e d that t h e y p u r c h a s e d s e v e r a l b o x e s of the s a m e type of c e r e a l . O n l y 1 m o t h e r bought a large s u p p l y of c e r e a l . T h e r e w e r e five m a i n o p e n - e n d e d r e s p o n s e s c i t e d b y the m o t h e r s a s important to infant c e r e a l b r a n d a n d t y p e s e l e c t i o n . T h e r e s p o n s e s , in the o r d e r of m o s t frequently cited w e r e ; b r a n d e x p o s u r e a n d p a c k a g i n g information (4/9), what w a s o n s a l e (3/9), k n o w l e d g e / a d v i c e o r b a b y p r e f e r e n c e s (2/9 e a c h ) , a n d c o n t e n t s (1/9). It is of interest that the ' m a r k e t i n g ' (7/9) a p p e a r e d to h a v e t h e m o s t i n f l u e n c e o n the m o t h e r s ' c e r e a l t y p e a n d b r a n d s e l e c t i o n , c o m p a r e d infant f o o d p r e f e r e n c e s (2/9) o r the c o n t e n t (1/9). Eight q u e s t i o n s w e r e d e v e l o p e d in s e c t i o n D of t h e q u e s t i o n n a i r e to e x p l o r e the m o t h e r s ' p e r c e p t i o n s of h e r infant's a c c e p t a n c e of c o m m e r c i a l infant c e r e a l s , the infant's diet a n d a p p e t i t e a n d t h e m o t h e r ' s level of c o n c e r n a b o u t s o l i d f o o d intake. M o s t of the m o t h e r s (7/9) s t a t e d that their infant h a d r e f u s e d t o e a t c o m m e r c i a l b a b y c e r e a l . In a d d i t i o n , m a n y m o t h e r s s t a t e d their infant preferred s p e c i f i c t e x t u r e s ( 6 / 9 ) , liked a variety of c e r e a l s (5/9), a n d liked different m e t h o d s of p r e p a r i n g c e r e a l s (7/9). A l t h o u g h two thirds of the m o t h e r s s t a t e d that their infant ate infant  119  RESULTS c e r e a l if t h e y h a d other c h o i c e s , o n e third s t a t e d that t h e y d i d not. Interestingly, m a n y m o t h e r s r e s p o n d e d that their infant's diet w a s nutritionally ' v e r y g o o d ' to 'excellent' (6/9), that their infant's appetite w a s a l s o ' v e r y g o o d ' to ' e x c e l l e n t ' (7/9), yet t h e y a l s o a p p e a r e d to h a v e c o n c e r n s a b o u t their infant's f o o d i n t a k e (6/9). U n f o r t u n a t e l y , s i n c e t h e s e q u e s t i o n s w e r e a s k e d at o n e point in time, it is not c l e a r f r o m the d a t a , at w h a t a g e c e r e a l s w e r e r e f u s e d , h o w m o t h e r s r e s p o n d e d to their infant's r e f u s a l of c e r e a l , at w h a t a g e ( s ) t h e m o t h e r s h a d c o n c e r n s a b o u t f o o d i n t a k e , o r what the food c o n c e r n s were. Fifteen q u e s t i o n s w e r e d e v e l o p e d in s e c t i o n E of t h e q u e s t i o n n a i r e to identify w h a t information a b o u t f e e d i n g s o l i d f o o d s t h e m o t h e r m a y h a v e u s e d . T h e q u e s t i o n s differentiated b e t w e e n t h e information that w a s r e c e i v e d v e r s u s that w h i c h w a s s o u g h t a n d its p e r c e i v e d u s e f u l n e s s . A l l of the m o t h e r s s t a t e d that t h e y both r e c e i v e d a n d s o u g h t information t h e m s e l v e s o n introducing s o l i d f o o d s . In a d d i t i o n , all of the m o t h e r s s t a t e d that t h e information that t h e y r e c e i v e d i n f l u e n c e d their f e e d i n g p r a c t i c e s a n d m o s t m o t h e r s s t a t e d that t h e information t h e y o b t a i n e d t h e m s e l v e s (7/9) i n f l u e n c e d their f e e d i n g p r a c t i c e s . O f interest, m a n y of the m o t h e r s (6/9) s t a t e d t h e information t h e y r e c e i v e d a n d the information t h e y s o u g h t t h e m s e l v e s (7/9) w a s not a d e q u a t e to m e e t their n e e d s . M a n y m o t h e r s r e c e i v e d information at birth o r in h o s p i t a l (5/9), or at a b o u t 3 m o n t h s p o s t p a r t u m (4/9). M o s t of t h e m o t h e r s (8/9) s o u g h t information later b e t w e e n 2 to 6 m o n t h s , a l t h o u g h a f e w (2/9) did s o at birth a s w e l l . T h e r e w e r e five s i t e s w h e r e the m o t h e r s r e c e i v e d information; the p a r e n t infant g r o u p s , their d o c t o r , t h e H o s p i t a l , b y m a i l a n d f r o m f r i e n d s . T h e m o t h e r s s o u g h t information at m o s t of t h e s e s i t e s a s w e l l , but i n s t e a d of the H o s p i t a l , t h e y s o u g h t information at the p u b l i c healt h unit, t h e b o o k s t o r e , the library, a n d f r o m f o r m u l a m a n u f a c t u r e r s a n d f o o d p a c k a g i n g . T h e m o t h e r s , in g e n e r a l , a p p e a r to h a v e r e c e i v e d m o r e information t h a n t h e y s o u g h t . V e r b a l information w a s r e c e i v e d f r o m the public h e a l t h n u r s e , d o c t o r , nutritionist, parent infant g r o u p , a n d f r i e n d s w h e r e a s information in print w a s r e c e i v e d b y m o t h e r s f r o m c h a r t s o n t i m i n g of s o l i d f o o d introduction, h a n d o u t s o n h o w to m a k e y o u r o w n f o o d , b o o k s a n d c o m m e r c i a l i n f o r m a t i o n . F u r t h e r , t h e m o t h e r s s o u g h t information f r o m t h e p u b l i c h e a l t h n u r s e s , t h e Nutritionist, f r i e n d s , b o o k s a n d a r t i c l e s . T h e information that t h e m o t h e r s r e c e i v e d a n d f o u n d  120  RESULTS m o s t helpful c o u l d b e d e s c r i b e d u s i n g their o w n w o r d s ; " a l l w a s useful" a n d "it's a g o o d introduction". S o m e m o t h e r s m e n t i o n e d that the t i m e c h a r t s w e r e g o o d b e c a u s e t h e y g a v e the o r d e r f o o d s w e r e to b e i n t r o d u c e d a n d a n a g e a p p r o p r i a t e practical timeline. O t h e r m o t h e r s s t a t e d that t h e information w a s s p e c i f i c a n d p r o v i d e d s o m e d e t a i l , 1 m o t h e r s t a t e d that t h e d o c t o r s ' a d v i c e w a s t r u s t e d . O f t h e information that t h e m o t h e r s s o u g h t , t h e y s t a t e d that t h e y f o u n d other m o t h e r s ' e x p e r i e n c e s , i d e a s , e d u c a t e d j u d g e m e n t a n d o n e to o n e information that w a s s p e c i f i c a n d d e t a i l e d , t h e m o s t u s e f u l . In a d d i t i o n , the c o m m e n t s about what information t h e y w o u l d h a v e liked, c o u l d b e d e s c r i b e d u s i n g t h e p h r a s e - " m o r e detail". T h e m o t h e r s w a n t e d m o r e detail in the t i m e l i n e s , m o r e detail s p e c i f i c to finger f o o d s a n d texture, daily m e a l p l a n s a n d a l l e r g y p r e v e n t i o n . O n e m o t h e r s t a t e d s h e w o u l d h a v e liked b o o k s o n nutrition a n d v i t a m i n s . T h e format u s e d to elicit r e s p o n s e s that c o u l d d i s t i n g u i s h b e t w e e n information that t h e m o t h e r r e c e i v e d v e r s u s w h a t s h e s o u g h t a t t e m p t e d to elicit d a t a o n the m o t h e r s ' viewpoint a b o u t the a v a i l a b l e r e s o u r c e s . T h e results of the s e c t i o n E q u e s t i o n n a i r e d a t a w e r e useful s i n c e t h e d a t a a d d e d a d d i t i o n a l detail that s u p p l e m e n t e d a s w e l l a s s u p p o r t e d the interview d a t a . A l t h o u g h the q u e s t i o n n a i r e d i d not elicit information a b o u t t h e m o t h e r s ' f e e l i n g s a b o u t b e i n g a 'first t i m e mother" (i.e. i n e x p e r i e n c e ) o r t h e i m p o r t a n c e of ' r e a s s u r a n c e ' to the mother, c o n c e p t s d i s c o v e r e d f r o m the interview d a t a , t h e y c o u l d b e e a s i l y i n c o r p o r a t e d into the q u e s t i o n n a i r e . T h e information g a t h e r e d f r o m t h e q u e s t i o n s a b o u t w h a t information w a s r e c e i v e d or s o u g h t ( E 1 a a n d E 2 a ) a n d the location that the m o t h e r w a s g i v e n , or h a d s o u g h t , information ( E 1 c a n d E 2 c ) w a s a n s w e r e d with s i m i l a r o r the s a m e a n s w e r s . It m a y b e p o s s i b l e to o r g a n i z e t h e s e q u e s t i o n s in a t a b l e format to h e l p r e s p o n d e n t s a n s w e r , m o r e e a s i l y , s u c h q u e s t i o n s that a r e c l o s e l y related yet slightly different (i.e. w h a t information did y o u r e c e i v e v e r s u s w h e r e did y o u r e c e i v e information). T w o q u e s t i o n s w e r e d e v e l o p e d in s e c t i o n F of the q u e s t i o n n a i r e to identify s o l i d f o o d f e e d i n g p r a c t i c e s , o t h e r t h a n c e r e a l f e e d i n g p r a c t i c e s . T h e q u e s t i o n s g i v e a n e x a m p l e of t h e d a t a that w o u l d b e c o l l e c t e d f r o m this format. A l t h o u g h all of the m o t h e r s h a d i n t r o d u c e d v e g e t a b l e s to their infant, 1 h a d not g i v e n fruit to h e r infant. M o s t of the m o t h e r s (7/9) h a d not i n t r o d u c e d e g g , a n d m a n y h a d not g i v e n c h e e s e s (4/9), o r yogurt (3/9) at t h e t i m e of the interview.  Interestingly,  m o s t m o t h e r s s t a t e d that t h e y h a d i n t r o d u c e d m e a t s (7/9). T h e 2 m o t h e r s ' w h o h a d not  121  RESULTS i n t r o d u c e d m e a t s , i n d i c a t e d that t h e y i n t e n d e d to d o s o at a b o u t 8 m o n t h s . T h e results f r o m this format, a l t h o u g h highly c o n d u c i v e to q u a n t i f i c a t i o n , d o not p r o v i d e important detail a b o u t the f e e d i n g p r o c e s s (i.e. the s p o r a d i c f e e d i n g of m e a t o v e r time) that t h e interview d a t a a n d / o r the d a t a f r o m the s p r e a d s h e e t f or m at in the q u e s t i o n n a i r e w e r e a b l e to elicit. T h e intent of the third s p r e a d s h e e t in the q u e s t i o n n a i r e w a s to elicit d a t a o n t h e m o t h e r s ' s o l i d f o o d f e e d i n g p r a c t i c e s , other t h a n c e r e a l f e e d i n g p r a c t i c e s , a c c o r d i n g to the infants' a g e . A l l of t h e m o t h e r s f e d their infants v e g e t a b l e s a n d a l l , e x c e p t 1, f e d their infant fruit at t h e t i m e of the interview. O f the t h r e e m o t h e r s w h o i n d i c a t e d starting fruits a n d / o r v e g e t a b l e s at 4 m o n t h s , 1 f e d a b o u t 3 to 4 t a b l e s p o o n s of e a c h p e r d a y f r o m 4 to 7 m o n t h s .  O n e mother fed about 1  t a b l e s p o o n of e a c h p e r d a y w o r k i n g u p to 1 s m a l l jar of e a c h p e r d a y b e t w e e n 7 to 8 m o n t h s . T h e other m o t h e r f e d a b o u t 2 t e a s p o o n s of fruit o n l y p e r d a y w o r k i n g up to Vz jar of fruit 3 t i m e s p e r w e e k a n d Vz jar of v e g e t a b l e s p e r d a y at 7 m o n t h s . T w o m o t h e r s s t a r t e d fruit o r v e g e t a b l e s at 5 m o n t h s of a g e . O n e of t h e s e m o t h e r s f e d a b o u t o n e half a t e a s p o o n but w o r k e d up to V* c u p of e a c h p e r d a y b y 7 m o n t h s a n d 1/3 c u p of e a c h p e r d a y b y 8 m o n t h s of a g e . T h e other m o t h e r f e d a b o u t 6 t a b l e s p o o n s of v e g e t a b l e s p e r d a y f r o m 4 to 7 m o n t h s a n d n o fruit. O n e m o t h e r s t a r t e d fruit at 6 m o n t h s a n d f e d a b o u t 1 to 2 t e a s p o o n s of fruit p e r d a y w o r k i n g up to i n c l u d i n g 3 i c e c u b e s i z e c h u n k s of h o m e m a d e v e g e t a b l e s p e r d a y 8 m o n t h s of a g e .  T h e a p p r o x i m a t e a m o u n t s of  fruit a n d v e g e t a b l e s f e d to t h e i n d i v i d u a l infants differed s u b s t a n t i a l l y at initial introduction, a s well a s o v e r t i m e . T h e t h r e e s p r e a d s h e e t s w e r e d e v e l o p e d for the q u e s t i o n n a i r e to identify the t y p e s , b r a n d s a n d a m o u n t s of liquids, c e r e a l s , a n d o t h e r s o l i d f o o d s that m o t h e r s f e d their infants o v e r t i m e . In addition to t h e interview d a t a , this t y p e of information a l s o a i d e d in identifying the factors within t h e f e e d i n g c o n t e x t that m a y i n f l u e n c e t h e infant's a c c e p t a n c e o r c o n s u m p t i o n of iron fortified infant c e r e a l s .  122  DISCUSSION  Chapter V  5.1  Determinants of solid food feeding practices A m o t h e r ' s s o l i d f o o d f e e d i n g p r a c t i c e s , w h i c h a r e d e t e r m i n e d , in part, b y the infant's f e e d i n g  b e h a v i o r s , h e r p e r c e p t i o n s , k n o w l e d g e a n d skills m u s t b e a p p r o p r i a t e to m e e t the infant's e v o l v i n g nutritional r e q u i r e m e n t s d u r i n g t h e transition p e r i o d (4 to 9 m o n t h s ) . P r e v i o u s s t u d i e s h a v e s h o w n that infants of 9 m o n t h s of a g e w h o a r e not bottle-fed with iron-fortified f o r m u l a a r e at high risk for iron d e f i c i e n c y a n e m i a a n d low iron s t o r e s . It is a l s o k n o w n , b a s e d o n iron n e e d s in the first y e a r of life a n d the iron c o n t e n t of h u m a n milk, that iron f r o m c o m p l e m e n t a r y f o o d s is e s s e n t i a l to prevent iron d e f i c i e n c y a n e m i a a n d iron d e p l e t i o n in b r e a s t - f e d infants of 9 - 12 m o n t h s of a g e . T h e p u r p o s e of this s t u d y w a s exploratory, to l e a r n a b o u t h o w m o t h e r s f e e d their infants a n d w h a t d e t e r m i n e s the w a y that t h e y f e e d s o l i d f o o d s d u r i n g t h e transition p e r i o d . T h i s information is important to d e v e l o p effective e d u c a t i o n s t r a t e g i e s that will i m p r o v e c o m p l e m e n t a r y s o l i d f o o d f e e d i n g p r a c t i c e s a n d h e n c e , the iron intake of infants at risk. T h i s r e s e a r c h identified 5 t h e m e s that a r e c e n t r a l to the s o l i d f o o d f e e d i n g p r o c e s s , a n d that o c c u r at 3 m a i n l e v e l s - t h e m o t h e r , the infant, a n d t h e e n v i r o n m e n t . A 3 - d i m e n s i o n a l c o n c e p t u a l m o d e l of infant s o l i d f o o d f e e d i n g h a s b e e n d e v e l o p e d to illustrate t h e s e t h e m e s ( F i g u r e 10). A s e c o n d c o n c e p t u a l m o d e l h a s b e e n d e v e l o p e d u s i n g a c a u s a l - c o n s e q u e n c e m o d e l ( G l a s e r , 1978) to illustrate t h e s o l i d f o o d f e e d i n g p r o c e s s . T h e s e c o n d m o d e l ( F i g u r e 15) links the r e l a t i o n s h i p s b e t w e e n the 5 t h e m e s a n d s u g g e s t s t h e potential c o n s e q u e n c e of t h e m o t h e r s ' s o l i d f o o d f e e d i n g p r a c t i c e s s p e c i f i c a l l y to d i e t a r y a d e q u a c y (i.e., iron). In this c h a p t e r the m o s t important a s p e c t s of t h e s e findings will b e d i s c u s s e d . Further, t h e s t u d y limitations a r e o u t l i n e d a n d t h e potential a p p l i c a t i o n of t h e f i n d i n g s to future r e s e a r c h a n d p r a c t i c e will b e d i s c u s s e d in C h a p t e r VI. S o l i d f o o d f e e d i n g is c o m p l e x a n d i n v o l v e s interactions at m a n y l e v e l s . W h e n v i e w e d simplistically, if nutrient n e e d s a r e to b e m e t then 1) the m o t h e r m u s t p r e p a r e a n d offer f o o d of t h e r e q u i r e d nutritional quality, a n d 2) t h e infant m u s t eat it. T h e results of this s t u d y c l e a r l y s h o w that all m o t h e r s started s o l i d f o o d f e e d i n g a n d all the m o t h e r s h a d the k n o w l e d g e to introduce iron-fortified infant c e r e a l at 4 - 6 m o n t h s . T h u s , l a c k of k n o w l e d g e of w h e n to i n t r o d u c e iron-fortified s o l i d f o o d s is not likely 123  DISCUSSION  to b e the p r o b l e m that c a u s e s a high i n c i d e n c e of iron d e p l e t i o n in b r e a s t - f e d infants. P r e v i o u s s t u d i e s h a v e reported that infants h a d b e e n i n t r o d u c e d to s o l i d f o o d s prior to 4 m o n t h s of a g e ( T a n a k a et a l . , 1 9 8 7 , Y e u n g et a l . , 1 9 8 1 , G r e e n e - F i n e s t o n e et a l . , 1 9 8 9 , C l a r k et a l . , 1 9 8 1 , W i l l i a m s et a l . , 1 9 9 6 ) . T h e r e h a s b e e n a trend t o w a r d s a later ( m o r e a p p r o p r i a t e ) a g e of introduction of s o l i d f o o d s o v e r the p a s t 2 0 y e a r s . W i l l i a m s et a l . (1996) f o u n d that o n l y 7 . 8 % of the infants in V a n c o u v e r h a d b e e n g i v e n ironfortified infant c e r e a l s b e f o r e 4 m o n t h s of a g e . In contrast, earlier w o r k b y T a n a k a et a l . (1984-85) a n d G r e e n e - F i n e s t o n e et a l . (1989) f o u n d that 4 2 % a n d 3 4 % of infants, r e s p e c t i v e l y , h a d b e e n i n t r o d u c e d to s o l i d s by 3 m o n t h s of a g e . P r e v i o u s to this, s t u d i e s in the 1 9 7 0 ' s f o u n d that 7 0 - 7 8 % of infants h a d b e e n i n t r o d u c e d to s o l i d s prior to 4 m o n t h s of a g e ( C l a r k et a l , 1 9 8 1 ) . T h e transcripts f r o m the f a c e - to - f a c e interviews with m o t h e r s in this s t u d y p r o v i d e a m p l e e v i d e n c e of k n o w l e d g e r e g a r d i n g t h e r e c o m m e n d e d a g e s for s o l i d f o o d introduction, with e x t e n s i v e d i s c u s s i o n a r o u n d the p e r c e i v e d infant's s o l i d f o o d likes a n d d i s l i k e s . T h e findings of this s t u d y s u g g e s t m o r e difficulties r e v o l v e d a r o u n d t h e infant e a t i n g t h e iron c o n t a i n i n g f o o d , t h a n the m o t h e r not k n o w i n g w h a t f o o d to offer. T h i s c a n b e s i m p l i s t i c a l l y d i v i d e d into h o w t h e m o t h e r p r e p a r e s a n d p r e s e n t s t h e f o o d , w h e n in the d a y s h e offers the f o o d , h o w s h e m a n a g e s the f e e d i n g e n v i r o n m e n t (i.e., the f e e d i n g d y n a m i c ) , h o w s h e interprets the infant's f o o d c u e s , a n d the infant's a c c e p t a n c e of the f o o d . T h e m o t h e r s w h o p a r t i c i p a t e d in this s t u d y took f r o m 2 w e e k s to o v e r 3 m o n t h s f r o m the t i m e of initial s o l i d f o o d 'introduction' a t t e m p t s to a c h i e v e (start) routine f e e d i n g of iron-fortified infant c e r e a l s . T h i s m a y b e d u e to infant f a c t o r s (i.e., flexible/inflexible p e r s o n a l i t y , ' g o o d ' / ' f u s s y ' eater) or m o t h e r f a c t o r s (i.e., f e e d i n g s t r a t e g i e s ) . T h e t r a n s c r i p t d a t a c l e a r l y s h o w that t h e r e w a s difficulty with c e r e a l a c c e p t a n c e (quantity a n d rate of a c c e p t a n c e ) for s o m e infants. T h e m o t h e r s d e s c r i b e d this period a s ' s p o r a d i c ' c e r e a l f e e d i n g . R e v i e w of t h e p u b l i s h e d literature o n infant f e e d i n g i n d i c a t e s that t h e r e is a l a c k of d a t a o n t h e t i m e o v e r w h i c h m o t h e r s a c h i e v e a p p r o p r i a t e s o l i d f o o d i n t a k e s . T h u s , the c o n c e p t s - s p o r a d i c a n d routine c e r e a l f e e d i n g , a d d to the current b o d y of literature. L a r g e quantitative p o p u l a t i o n s t u d i e s i n v e s t i g a t i n g the growth a n d / o r nutrient s t a t u s of y o u n g infants (Walter et a l . , 1 9 9 3 ; D e w e y et a l . , 1 9 9 8 ; Innis et a l . , 1 9 9 7 ; C a l v o et a l . , 1 9 9 0 ; P i z a r r o et a l . , 1 9 9 1 ; H e i n i g et a l . , 1993) h a v e u s e d the ' a g e of introduction of s o l i d f o o d s ' a s a v a r i a b l e for identifying f a c t o r s that i n f l u e n c e infant iron s t a t u s or g r o w t h . P i z a r r o et a l . , (1991), W a l t e r et a l . , (1993) a n d o t h e r s ( S i i m m e s et a l . , 1984) h a v e s h o w n a n i n c r e a s e d risk of iron d e f i c i e n c y a n e m i a in infants after a b o u t 6 m o n t h s of a g e if a d d i t i o n a l c o m p l e m e n t a r y 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 'routinely or 1  '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 'ready for solid foods or disliking the food. It seems likely, based on the transcripts that 1  some mothers may have misinterpreted the infants' food refusal cues as the infant not being 'ready for 1  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  f o o d s s u c h a s m e a t , f i s h , a n d poultry. T h e results of this s t u d y s h o w that t h e r e a r e s e v e r a l critical i s s u e s with r e g a r d s to t h e practical a p p l i c a t i o n of current infant f e e d i n g r e c o m m e n d a t i o n s b y m o t h e r s . First, t h e m o s t frequent s o l i d f o o d r e j e c t e d b y the infants w a s iron-fortified c e r e a l . Further, all of the m o t h e r s in this s t u d y u s e d a ' m i x i n g ' strategy to i n c r e a s e o r m a i n t a i n f o o d a c c e p t a n c e (mixing to alter taste/texture) o r get s o l i d f o o d e a t e n (mixing d i s l i k e d f o o d s with preferred f o o d s ) . T h i r d , the n u m b e r of m o t h e r s a m o n g t h e s e m o r e highly e d u c a t e d a n d m o t i v a t e d s t u d y participants w h o a c h i e v e d t h e r e c o m m e n d e d f e e d i n g of 4 t a b l e s p o o n s of c e r e a l p e r d a y b y 6 m o n t h s of a g e w a s low (4/12). L a s t l y , it t o o k 3 m o n t h s for m a n y of the m o t h e r s (6/12) to r e a c h routine f e e d i n g s of V* c u p of c e r e a l p e r d a y f r o m the reported initial a g e of c e r e a l introduction. C l e a r l y , it is r e a s o n a b l e to c o n c l u d e that the intake of iron f r o m iron-fortified infant c e r e a l differed a m o n g the infants in this s t u d y . T h i s s t u d y f o u n d that t h e m o t h e r s u s e d n u m e r o u s a n d d i v e r s e infant f e e d i n g s t r a t e g i e s . T h e transcript d a t a s u g g e s t that the infant's dietary intake m a y h a v e differed d e p e n d i n g o n the s t r a t e g y that the mother used. T h e solid food feeding strategies u s e d by the mothers are represented by the t h e m e w a y s of f e e d i n g . N o literature o n infant f e e d i n g that w e k n o w of h a s d e s c r i b e d s o l i d f o o d f e e d i n g s t r a t e g i e s . T h i s finding a d d s to t h e b o d y of k n o w l e d g e o n infant f e e d i n g a n d i n c r e a s e s the u n d e r s t a n d i n g of t h e link b e t w e e n the f e e d i n g b e h a v i o r s , infant f o o d a c c e p t a n c e , a n d the s u c c e s s of the s o l i d f o o d f e e d i n g p r o c e s s with r e g a r d s to nutritional a d e q u a c y . T h e r a n g e of infant f e e d i n g s t r a t e g i e s identified b y this r e s e a r c h c a n b e simplistically d e s c r i b e d a s s t r a t e g i e s that p o s s i b l y p r o m o t e (positive), a r e ineffective (neutral), or c o u l d b e c o n s i d e r e d a s d i s c o u r a g i n g (negative) s o l i d f o o d a c c e p t a n c e . T h e m o t h e r s d i s c u s s e d in detail h o w t h e y p r e p a r e d a n d f e d their infant s o l i d f o o d s . T h e m o t h e r s u s e d s e v e r a l f e e d i n g s t r a t e g i e s that a p p e a r e d to b e in r e s p o n s e to infant f o o d p r e f e r e n c e s ; t h e s e s t r a t e g i e s a p p e a r e d to b e r e s p o n s e s ( c h a n g e s ) in the m o t h e r ' s f e e d i n g b e h a v i o r to d e c r e a s e the infant's rejection of the f o o d . T h e s e s t r a t e g i e s i n c l u d e d s w i t c h i n g (types of f o o d a n d / o r b r a n d s of c e r e a l s ) , m i x i n g (to alter t a s t e or textures of c e r e a l s a n d other s o l i d f o o d s ) , s n e a k i n g or c a m o u f l a g i n g f o o d (mixing p r e f e r r e d f o o d s with d i s l i k e d f o o d s to get the f o o d eaten) a n d p o s s i b l y holding back s p e c i f i c a c c e p t e d f o o d s in o r d e r to a c h i e v e a c c e p t a n c e of a d i s l i k e d f o o d . T h e m o t h e r s a l s o a p p e a r e d to b e c h a n g i n g ' w h e n in t h e d a / t h e y offered the f o o d , l a b e l e d a s adjusting f e e d i n g m a n a g e m e n t , to i m p r o v e f o o d a c c e p t a n c e . T h e s e s t r a t e g i e s of c h a n g i n g w h e n the infant w a s f e d i n c l u d e d adjusting the f r e q u e n c y of f e e d s ,  126  DISCUSSION  the o r d e r in w h i c h f o o d s w e r e f e d , a d j u s t i n g f e e d i n g routines a n d p o s s i b l y holding  back liquids (e.g.,  b r e a s t - f e e d i n g ) to i n c r e a s e h u n g e r . T h e transcripts for this s t u d y a l s o g i v e e v i d e n c e that h o w t h e m o t h e r interpreted h e r infant's f o o d c u e s m a y h a v e d e t e r m i n e d the f e e d i n g s t r a t e g i e s that w e r e u s e d . T h e s t r a t e g i e s that m a y h a v e b e e n u s e d in r e s p o n s e to t h e m o t h e r ' s interpretation of infant r e a d i n e s s for f o o d w e r e offering t h e s a m e f o o d s r e p e a t e d l y w h e t h e r t h e infant liked or d i s l i k e d t h e f o o d , waiting for the infant to b e c o m e i n t e r e s t e d , a n d withholding f o o d b e c a u s e of p e r c e i v e d a l l e r g y risk, c h o k i n g risk, a n d texture difficulties (immaturity/unready). Further, the s t r a t e g y positioning  the infant horizontally ( e . g . lying o n b a c k ) to  p r o m o t e s w a l l o w i n g m a y reflect a s t r a t e g y to d e a l with the infant's d e v e l o p m e n t a l r e a d i n e s s (e.g., infant w a s not r e a d y ) . T h e f e e d i n g s t r a t e g i e s that s e e m e d m o s t likely to h a v e h a d a n e g a t i v e effect o n the f e e d i n g d y n a m i c / r e l a t i o n s h i p w e r e prying/stuffing/ c a r s e a t ) , sneaking/camouflaging  forcing t h e infant to eat, positioning  (restraining infant in  o r hiding (disliked f o o d s m i x e d with liked f o o d s ) a n d distracting  (using  t o y s to alter d y n a m i c s to g e t f o o d e a t e n ) . W h i l e p o s s i b l y p o s i t i v e s t r a t e g i e s m a y h a v e i n c l u d e d socializing  (family m e a l s ) , modeling  or mimicking  h o w to eat, engaging  control in f e e d i n g b y a l l o w i n g t h e m to hold the s p o o n , a n d playing  (giving t h e infant s o m e d e g r e e of  (food p l a y - e x p l o r i n g ) .  T h e c l a s s i f i c a t i o n of s o l i d f o o d f e e d i n g s t r a t e g i e s in this s t u d y s u g g e s t s patterns of h o w s o l i d f o o d s w e r e f e d to the infants b y the different m o t h e r s in this s t u d y . C o m m e r c i a l infant c e r e a l is fortified with iron a n d is t h e o n l y a p p r e c i a b l e s o u r c e of c o m p l e m e n t a r y f o o d iron f e d to m o s t infants u n d e r  7 - 9  m o n t h s of a g e . S u l l i v a n a n d B i r c h (1994) i n v e s t i g a t e d r e p e a t e d e x p o s u r e of t h e s a m e or s i m i l a r f o o d s o n v e g e t a b l e a c c e p t a n c e a n d f o u n d that all t h e infants (n=36) in their s t u d y i n c r e a s e d their v e g e t a b l e i n t a k e after r e p e a t e d e x p o s u r e . S i n c e b r e a s t - f e d infants h a d a g r e a t e r v e g e t a b l e intake t h a n f o r m u l a f e d infants, the a u t h o r s s u g g e s t e d that b r e a s t - f e e d i n g might facilitate s o l i d f o o d a c c e p t a n c e . B i r c h et a l . (1998) f o u n d that t h e n u m b e r of f e e d i n g s n e e d e d to i n c r e a s e the intake of a s i m i l a r c o m p a r e d to a n o v e l f o o d d i f f e r e d . Infants of 4 - 7 m o n t h s a c c e p t e d s i m i l a r f o o d s e a s i l y after e x p o s u r e , w h e r e a s t h e y did not a c c e p t different f o o d s (e.g., v e g e t a b l e c o m p a r e d to fruit) e a s i l y . Further, M e n n e l l a a n d B e a u c h a m p (1997) r e p o r t e d that b o t h c e r e a l a c c e p t a n c e a n d t h e quantity of c e r e a l c o n s u m e d b y b r e a s t - f e d infants w a s i n f l u e n c e d b y t h e p r e p a r a t i o n m e t h o d . T h e infants c l e a r l y p r e f e r r e d c e r e a l p r e p a r e d with a liquid that t h e y liked ( m o t h e r ' s milk c o m p a r e d to water), c o n s u m e d it at a f a s t e r rate, a n d p r e f e r r e d the mixture m a d e with the m o t h e r s milk w h e n it w a s o f f e r e d to t h e m a Vz h o u r later. T h e t r a n s c r i p t s f r o m this s t u d y s h o w that all 127  DISCUSSION  of the m o t h e r s u s e d a c e r e a l ' m i x i n g ' s t r a t e g y to i n c r e a s e s o l i d f o o d a c c e p t a n c e . T h i s s u g g e s t s that t h e m o t h e r s m o d i f i e d h o w t h e y p r e p a r e d their infant's f o o d to a c h i e v e a c c e p t a n c e a n d / o r to c o m p l y with infant f o o d p r e f e r e n c e s . T h u s , it s e e m s likely, that in t h e n a t u r a l f e e d i n g c o n t e x t infant f o o d a c c e p t a n c e a n d p r e f e r e n c e s a r e c l o s e l y intertwined with the m o t h e r ' s f e e d i n g s t r a t e g y (how the f o o d is p r e p a r e d ) . T h e m o t h e r s in this s t u d y d e s c r i b e d 3 ' m i x i n g ' m e t h o d s , w h i c h c a n all b e d e s c r i b e d a s " p r e p a r a t i o n of a c o m p l e x m e a l ' . T h e 3 m e t h o d s w e r e c o m m e r c i a l l y p r e - m i x e d c e r e a l c o m b i n a t i o n s ( e . g . c e r e a l with fruit), h o m e m a d e m i x t u r e s u s i n g a c o m b i n a t i o n of c o m m e r c i a l infant c e r e a l with fruit, v e g e t a b l e s , or yogurt, o r f e e d i n g o t h e r s o l i d f o o d s at the s a m e t i m e a s c e r e a l but ' o n the s i d e ' . A l t h o u g h the m o t h e r s u s e d different p r e p a r a t i o n s t r a t e g i e s to alter the f o o d t a s t e a n d / o r texture a n d t h u s i n c r e a s e a c c e p t a n c e , t h e s e 3 m i x i n g m e t h o d s might i n f l u e n c e c e r e a l a c c e p t a n c e a n d h e n c e c o n s u m p t i o n differently.  Further, ' m i x i n g ' a s a s t r a t e g y to g a i n a c c e p t a n c e r a i s e s t h e q u e s t i o n of potential d i f f e r e n c e s  in iron a b s o r p t i o n s e c o n d a r y to t h e t y p e of f o o d c o m b i n e d with t h e c e r e a l . T h e f o r m of iron in infant c e r e a l is n o n - h e m e iron, w h i c h h a s a w i d e r a n g e of a b s o r p t i o n of 5 - 2 0 % , d e p e n d i n g o n f a c t o r s e n h a n c i n g o r inhibiting iron a b s o r p t i o n in t h e diet ( H a l l b e r g , 1 9 8 9 ) , a n d the iron s t a t u s of the i n d i v i d u a l . T h e m a j o r f a c t o r s e n h a n c i n g the a b s o r p t i o n of n o n - h e m e iron i n c l u d e a s c o r b i c a c i d , m e a t a n d f i s h , a n d o r g a n i c a c i d s (citric, lactic, m a l i c , a n d tartaric a c i d s ) . T h e m a j o r f a c t o r s that inhibit n o n - h e m e iron a b s o r p t i o n i n c l u d e ; p h y t a t e s (found in high fiber c e r e a l s ) , iron-binding p o l y p h e n o l s f o u n d in t e a a n d c o f f e e , v e g e t a b l e s a n d fruits, s o m e proteins ( e g g a l b u m i n , a n d l e g u m e protein), a n d s o m e i n o r g a n i c e l e m e n t s ( c a l c i u m ) ( F a i r w e a t h e r - T a i t , 1 9 8 9 ) . T h u s , d e p e n d i n g o n t h e f o o d c o m b i n a t i o n , iron a b s o r p t i o n f r o m c e r e a l o r b r e a s t milk m a y b e e n h a n c e d or inhibited. F o r e x a m p l e , in the context of m i x e d f o o d c o m b i n a t i o n s , the p h y t a t e s in t h e c e r e a l m a y i n f l u e n c e h u m a n milk iron a b s o r p t i o n if c e r e a l s a r e f e d in c l o s e proximity to b r e a s t - f e e d i n g . A n o t h e r e x a m p l e is t h e p o l y p h e n o l s in v e g e t a b l e s a n d fruits or t h e c a l c i u m in yogurt that m a y d e c r e a s e t h e a b s o r p t i o n of iron f r o m infant c e r e a l . R e c e n t l y , E n g e l m a n n et a l . , (1988) f o u n d that n o n - h e m e iron a b s o r p t i o n b y infants w a s i n c r e a s e d to 1 5 % f r o m 9 . 9 % w h e n m e a t w a s a d d e d t o a v e g e t a b l e mixture. T h i s s u g g e s t s that iron a b s o r p t i o n f r o m infant diets of low or i n t e r m e d i a t e iron bioavailability c o u l d b e i m p r o v e d b y c h a n g e s in the p r e p a r a t i o n m e t h o d to i n c r e a s e t h e b i o a v a i l a b i l i t y of the iron p r e s e n t .  128  DISCUSSION  T h e transcript results f r o m this s t u d y a l s o s h o w that the p r o g r e s s i o n of the f e e d i n g p r o c e s s reflected a m o t h e r ' s ' l e a r n i n g ' o n h o w to f e e d h e r infant. T h e results s u g g e s t that the m o t h e r ' s k n o w l e d g e , s k i l l s a n d f e e d i n g c a p a b i l i t y w e r e important d e t e r m i n a n t s of t h e ability to m o d i f y f e e d i n g s t r a t e g i e s in r e s p o n s e to p e r c e i v e d infant f o o d c u e s . F o r s e v e r a l m o t h e r s , the 'initial' f e e d i n g b e h a v i o r s a p p e a r e d to b e ' f o r c e ' f e e d i n g , d e s p i t e p h y s i c a l s i g n s f r o m the infant that t h e y did not want f o o d . T h e f e e d i n g s t r a t e g i e s prying/stuffing/forcing, d i s t r a c t i n g , s n e a k i n g o r c a m o u f l a g i n g f o o d , a n d p u s h i n g o r holding b a c k f o o d might c a u s e difficulties in f e e d i n g a n d p o s s i b l y reflect g a p s in the m o t h e r ' s k n o w l e d g e , skills a n d t h u s c a p a b i l i t y . S a t t e r (1990) n o t e d that effective f e e d i n g i n c l u d e s b e h a v i o r s that a r e s u p p o r t i v e a n d p r o m o t e p o s i t i v e f e e d i n g d y n a m i c s . T h e f o o d r e f u s a l d i s c u s s e d b y s o m e m o t h e r s in this s t u d y c o u l d b e e x p l a i n e d b y s e v e r a l f a c t o r s s u c h a s inappropriate timing, inappropriate e x p e c t a t i o n s a b o u t t h e quantity of f o o d a n infant s h o u l d eat, m i s i n t e r p r e t e d f o o d p r e f e r e n c e s c u e s , a n d limited opportunities for the infant to e x p l o r e t h e f o o d o f f e r e d .  T h e infant c u e s d e s c r i b e d , s u c h a s spitting f o o d  out or retching c o u l d indicate a l a c k of infant d e v e l o p m e n t a l r e a d i n e s s (gag a n d s w a l l o w reflex not fully mature), or alternately a n i n a p p r o p r i a t e f e e d i n g m e t h o d (i.e., p u s h i n g the s p o o n t o o far b a c k in t h e infant's m o u t h ) . " T u r n i n g d o w n f o o d , spitting it out, not o p e n i n g m o u t h , turning h e a d ' etc., a r e b e h a v i o r s that c o u l d a l s o i n d i c a t e a n infant's p r e f e r e n c e for s w e e t rather t h a n bitter flavors ( M e n n e l l a a n d B e a u c h a m p , 1 9 9 8 ) . T h u s , the interpretation of f o o d refusal i n v o l v e s both the m o t h e r ' s interpretation of the v a r i o u s f o o d c u e s , the m o t h e r ' s f e e d i n g skill a n d k n o w l e d g e of infant d e v e l o p m e n t a n d b e h a v i o r , a s well a s t h e f e e d i n g r e l a t i o n s h i p . T h e o u t c o m e in t h e p r o g r e s s i o n of f e e d i n g is d e p e n d e n t o n h o w t h e m o t h e r a d a p t s a n d w h a t s h e l e a r n s f r o m the infant's r e s p o n s e to her a c t i o n s . Infant f e e d i n g g u i d e l i n e s ( C P S , 1 9 9 8 ; B . C . M i n i s t r y of H e a l t h , 1 9 9 6 ) h a v e not a d d r e s s e d i s s u e s of infant f o o d a c c e p t a n c e a n d r e f u s a l , o r t h e c o m p l e x a s p e c t of ' h o w ' to f e e d infants s o l i d f o o d s . T h e f i n d i n g s of this r e s e a r c h s h o w that m o t h e r s r e c o g n i z e c o n c e p t s f r o m the infant f e e d i n g g u i d e l i n e s s u c h a s g e n e r a l r e a d i n e s s , f o o d p r e f e r e n c e s , h u n g e r o r s a t i e t y c u e s , a n d t h e y k n o w w h e n to introduce first f o o d s ( c e r e a l s ) . H o w e v e r , in t h e c a s e of f o o d r e f u s a l , it s e e m s likely that m o t h e r s m a y not h a v e t h e k n o w l e d g e o r skills to r e s p o n d appropriately.  F i v e t h e m e s w e r e identified a s critical to s o l i d f o o d f e e d i n g d u r i n g t h e transition p e r i o d a n d w e r e defined as  the feeding process, perceiving infant food needs, ways of feeding, gaining expertise  and  tailoring the transition process. T h e s e t h e m e s a r e i n t e r c o n n e c t e d . W i t h i n the c o n t e x t of the infant f e e d i n g 129  DISCUSSION  p r o c e s s , m a n y f a c t o r s i n f l u e n c e ' h o w ' a m o t h e r f e e d s h e r infant. T h e k e y f a c t o r s that d e t e r m i n e infant solid f o o d f e e d i n g , b e s i d e s infant f o o d a c c e p t a n c e , a r e the m o t h e r ' s p e r c e p t i o n s , f e e d i n g s t r a t e g i e s a n d h e r e x p e r t i s e . T h i s s t u d y identified a c o r e t h e m e -  tailoring the transition process  that c o n n e c t s the other  4 t h e m e s t o g e t h e r a n d b e s t d e s c r i b e s t h e m o t h e r ' s m a j o r f e e d i n g t a s k d u r i n g t h e transition p e r i o d . T w o m o d e l s w e r e d e v e l o p e d to d e s c r i b e the p r o c e s s t h r o u g h w h i c h t h e m o t h e r is  tailoring h e r  feeding  s t r a t e g i e s . T h e c o n c e p t 'tailoring' is central to u n d e r s t a n d i n g t h e infant's dietary p r o g r e s s i o n ( a c c e p t a n c e of a n i n c r e a s i n g a m o u n t a n d r a n g e of s e m i - s o l i d f o o d s ) f r o m the e x c l u s i v e l y liquid diet to a m o d i f i e d adult diet, a n d u n d e r s t a n d i n g dietary iron a d e q u a c y . T o e m p h a s i z e this, t h e c o r e t h e m e c a n b e further d e s c r i b e d a l o n g a d i m e n s i o n of 'tailoring' o r not 'tailoring' t h e transition p r o c e s s . T h e interview t r a n s c r i p t s c l e a r l y s h o w that s o m e of the m o t h e r s in this s t u d y r e a d i l y a d a p t e d a n d u s e d multiple s t r a t e g i e s a n d w e r e t h u s tailoring their f e e d i n g p r a c t i c e s . O t h e r s , h o w e v e r , u s e d a limited n u m b e r of s t r a t e g i e s . T h e f e e d i n g s t r a t e g i e s differed in their e f f e c t i v e n e s s . R e p e a t e d f o o d 'offering' a n d 'waiting' for the infant to b e c o m e interested c a n b e c o n s i d e r e d a s 'static ' o r not 'tailored' in that t h e y a p p e a r e d to not p r o m o t e s o l i d f o o d a c c e p t a n c e (i.e., c e r e a l ) or t h e p a c e of f o o d transition a s s u c c e s s f u l l y a s other s t r a t e g i e s . T h e f o o d 'switching' a n d ' m i x i n g ' s t r a t e g i e s c a n b e c o n s i d e r e d to b e m o r e ' d y n a m i c ' in that t h e m o t h e r 'tailored' h e r f e e d i n g s t r a t e g y a c c o r d i n g to t h e infant's r e s p o n s e to t h e f o o d that w a s o f f e r e d . T h e s w i t c h i n g a n d m i x i n g s t r a t e g i e s a p p e a r e d to b e m o r e s u c c e s s f u l in p r o m o t i n g t h e a c c e p t a n c e of s o l i d f o o d a n d the transition p a c e . T h e m o t h e r s w h o w e r e 'tailoring' their s o l i d f o o d f e e d i n g s t r a t e g i e s a p p e a r e d to b e d e l i b e r a t e l y s e a r c h i n g for ' w a y s ' to i n c r e a s e f o o d a c c e p t a n c e . A l t h o u g h this s t u d y f o u n d t h a t '  tailoring the transition process'  w a s the c o r e t h e m e , the m o t h e r ' s  infant f e e d i n g k n o w l e d g e , skills a n d c a p a b i l i t y a r e a l s o central to u n d e r s t a n d i n g t h e infant's dietary p r o g r e s s i o n . T h e m o t h e r ' s p e r s o n a l g r o w t h w a s l a b e l e d ' g a i n i n g e x p e r t i s e ' . T h e e x p e r i e n c e of b e i n g a 'first time' m o t h e r a n d n e e d i n g infant s o l i d f o o d f e e d i n g information a n d s u p p o r t (including ' r e a s s u r a n c e ' ) w a s d e s c r i b e d in detail in t h e t r a n s c r i p t s . G r e e n a n d K r e u t e r (1991) state that l e a r n i n g i n v o l v e s t h r e e p r o c e s s e s : direct e x p e r i e n c e , indirect or v i c a r i o u s e x p e r i e n c e f r o m the o b s e r v a t i o n of o t h e r s (modeling), a n d u n d e r s t a n d i n g c o m p l e x information to e n a b l e the anticipation of c o n s e q u e n c e s of o n e s o w n a c t i o n s a n d c a p a b i l i t i e s . G r e e n a n d K r e u t e r (1991) a l s o n o t e d that the last p r o c e s s is c e n t r a l to the i n d i v i d u a l ' s s e n s e of c o n f i d e n c e in n e w situations or c i r c u m s t a n c e s . Further, t h e s e a u t h o r s state that the p e r c e p t i o n of 'self-efficacy o r c a p a c i t y for s u c c e s s b a s e d o n e x p e r i e n c e i n f l u e n c e s e m o t i o n a l r e a c t i o n s with r e g a r d s 1  130  DISCUSSION  to a n x i e t y a n d c o p i n g ability ( G r e e n a n d K r e u t e r , 1 9 9 1 ) . T h e m o t h e r s in this s t u d y d e s c r i b e d their e x p e r i e n c e s m o v i n g a l o n g a ' l e a r n i n g c u r v e ' with t h e relatively n e w ' c i r c u m s t a n c e ' of s o l i d f o o d f e e d i n g . T h e m o t h e r s e x p r e s s e d v a r i o u s l e v e l s of frustration with u n s u c c e s s f u l initial attempts at s o l i d f o o d f e e d i n g , or w h e n t h e f e e d i n g situation d i d not g o a s t h e y h a d e x p e c t e d . A l t h o u g h m o s t m o t h e r s identified a n d u s e d n u m e r o u s r e s o u r c e s for information o n infant f e e d i n g , t h e y c l e a r l y articulated g a p s in the r e s o u r c e s a v a i l a b l e for their situation a n d information n e e d s . T h e r e s o u r c e s that w e r e u s e d i n c l u d e d t h e p r o f e s s i o n a l s e c t o r (health n u r s e s , nutritionists, d o c t o r s , c o m m u n i t y g r o u p s , parent g r o u p s a n d t h e nutrition hotline), p r o f e s s i o n a l g u i d e l i n e s a n d c h a r t s , t h e p o p u l a r p r e s s , p a m p h l e t s p r e p a r e d b y b a b y f o o d c o m p a n i e s for p r o d u c t s a n d for f o o d p a c k a g i n g , a n d the m o t h e r ' s s o c i a l network (family, friends a n d m o t h e r s ' g r o u p s ) . T h i s s t u d y f o u n d that m o t h e r s h a d the m o s t difficulty with l e a r n i n g ' h o w ' to f e e d their infant s o l i d f o o d s , not w h e n o r w h a t f o o d to start with. T h e transcripts c l e a r l y identify that t h e e x p e r i e n c e of b e i n g a 'first t i m e m o m ' p r o d u c e d f e e l i n g s of u n c e r t a i n t y in m a n y m o t h e r s , a n d this m a y h a v e i n f l u e n c e d f e e d i n g c o n f i d e n c e . S o m e m o t h e r s s t a t e d that t h e y e v e n felt s c a r e d a b o u t f e e d i n g their infant. It is p o s s i b l e that m o t h e r s w h o did not h a v e k n o w l e d g e o r e x p e r i e n c e s of ' h o w ' to f e e d their infant s o l i d f o o d a n d w h o h a d f e e d i n g c h a l l e n g e s , s u c h a s f o o d rejection o r c o n c e r n s a b o u t s l o w infant w e i g h t g a i n , w e r e e x p r e s s i n g f e e l i n g s that i n v o l v e d p e r c e p t i o n s of s e l f - e f f i c a c y a n d their c a p a b i l i t i e s . S o m e m o t h e r s d e s c r i b e d h a v i n g to g o with their  gut feeling'  a n d w h a t t h e y t h o u g h t w a s right  or 'best for their baby' with  'own  r e g a r d s to f e e d i n g s o l i d f o o d s .  T h e s e m o t h e r s a l s o d e s c r i b e d l e a r n i n g to f e e d their infant a s a 'trial a n d error p r o c e s s . T h i s s u g g e s t s 5  that in l e a r n i n g to f e e d their infant, m o t h e r s might p r o g r e s s t h r o u g h a 'reflective' learning p r o c e s s that might benefit f r o m p e e r or p r o f e s s i o n a l s u p p o r t that w o u l d reinforce p o s i t i v e s o l i d f o o d f e e d i n g p r a c t i c e s o r alternately, redirect n e g a t i v e p r a c t i c e s . S i n c e l e a r n i n g t a k e s p l a c e t h r o u g h direct e x p e r i e n c e , a s w e l l a s b y o b s e r v i n g o t h e r s ( G r e e n a n d K r e u t e r , 1 9 9 1 ) it m a k e s s e n s e that the m o t h e r s in this s t u d y f o u n d that ' e x p e r i e n c e d ' m o t h e r s w e r e m o s t helpful a n d that t h e y felt r e a s s u r e d t h r o u g h interaction with other m o t h e r s at the c o m m u n i t y g r o u p s e t t i n g s . Infant f e e d i n g g u i d e l i n e s ( C P S , 1 9 9 8 ; B . C . Ministry of H e a l t h , 1 9 9 6 ) a d d r e s s ' w h e n ' to start f e e d i n g s o l i d f o o d s a n d 'what first f o o d s ' s h o u l d b e f e d (i.e., iron-fortified infant c e r e a l ) . T h e findings f r o m this s t u d y c l e a r l y s u g g e s t that m o t h e r s m a y n e e d a d d i t i o n a l r e s o u r c e s that f o c u s explicitly o n i s s u e s a r o u n d p r o m o t i n g infant f o o d a c c e p t a n c e a n d d e c r e a s i n g f o o d r e f u s a l - t h e c o m p l e x a s p e c t of ' h o w to f e e d infants s o l i d f o o d s , a n d i s s u e s a r o u n d b e i n g a 'first time' m o t h e r m o v i n g 1  131  DISCUSSION  t h r o u g h a 'reflective' l e a r n i n g p r o c e s s . T h i s a p p r o a c h , w h i c h f o c u s e s o n factors that a r e related to t h e mother, the infant a n d t h e e n v i r o n m e n t (i.e., r e s o u r c e s ) w o u l d p r e p a r e the m o t h e r better for the t a s k of 'tailoring the transition p r o c e s s ' .  5.2  The conceptual models of infant solid food feeding  T h e 3 - d i m e n s i o n a l c o n c e p t u a l m o d e l ( F i g u r e 10) a n d 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 s o l i d f o o d f e e d i n g ( F i g u r e 15) w e r e d e v e l o p e d to illustrate the d e t e r m i n a n t s of the s o l i d f o o d f e e d i n g p r a c t i c e s during the transition p e r i o d of t h e m o t h e r s in this s t u d y u s i n g the t h e m e s d i s c o v e r e d in the interview d a t a . A c o n c e p t u a l m o d e l in qualitative e x p l o r a t o r y r e s e a r c h is important for integrating f i n d i n g s .  Through  integration of c o n c e p t s a n d c a t e g o r i e s , t h e a n a l y s i s p r o g r e s s e s f r o m b e i n g s o l e l y d e s c r i p t i v e to b e i n g c o n c e p t u a l a n d t h e o r e t i c a l , w h i c h is t h e p u r p o s e of the g r o u n d e d t h e o r y m e t h o d ( G l a s e r a n d S t r a u s s , 1 9 6 7 ; G l a s e r , 1 9 7 8 ; S t r a u s s a n d C o r b i n , 1 9 9 0 ) . C o n c e p t u a l m o d e l s facilitate the d i s c o v e r y of r e l a t i o n s h i p s a m o n g c o n c e p t s a n d c a t e g o r i e s identified f r o m within the context a n d a r e d e v e l o p e d f r o m the a n a l y s i s p r o c e s s itself. C o n s e q u e n t l y , the s o l i d f o o d f e e d i n g m o d e l s d e v e l o p e d in this s t u d y a r e ' g r o u n d e d ' both c o n c e p t u a l l y to t h e interview d a t a a n d d e v e l o p e d f r o m the d a t a . T h e s e c o n c e p t u a l m o d e l s a d d to p r e s e n t k n o w l e d g e b e c a u s e t h e y illustrate the c o m p l e x interaction b e t w e e n t h e m o t h e r , infant, f o o d a n d the f a c t o r s in the s o l i d f o o d f e e d i n g c o n t e x t that d e t e r m i n e d s o l i d f o o d f e e d i n g p r a c t i c e s . T h u s , the m o d e l s p r o v i d e a f r a m e w o r k of the infant b e h a v i o r s , the m o t h e r s ' p r a c t i c e s , a n d t h e d e t e r m i n a n t s within t h e m o t h e r s ' ' p r o x i m a l ' e n v i r o n m e n t s that i n f l u e n c e the ability to f e e d the r e c o m m e n d e d a m o u n t s of c o m p l e m e n t a r y s o l i d f o o d s during the transition p e r i o d . T h e f r a m e w o r k that p r o v i d e s structure to t h e m o d e l s is d e r i v e d f r o m the c a u s a l - c o n s e q u e n c e m o d e l ( G l a s e r , 1978). T h u s , t h e f e e d i n g p r o c e s s c a n b e d e s c r i b e d a c c o r d i n g to the context, c o n d i t i o n s ( g e n e r a l , c a u s a l a n d intervening), t h e c o r e c a t e g o r y a n d t h e c o n s e q u e n c e s ( S t r a u s s a n d C o r b i n , 1 9 9 0 ) . Inappropriate 'tailoring' is illustrated a s a c o n s e q u e n c e that i m p a c t s o n s o l i d f o o d a c c e p t a n c e a n d c o n s u m p t i o n patterns (iron-fortified infant c e r e a l ) at s p e c i f i c a g e s . T h e c o n s e q u e n c e s of i n a d e q u a t e dietary iron intake h a v e b e e n s t u d i e d e x t e n s i v e l y t h r o u g h r e s e a r c h identifying t h e p r e v a l e n c e of iron d e f i c i e n c y a n e m i a a n d iron d e f i c i e n c y in infants.  132  Less  DISCUSSION  r e s e a r c h h a s f o c u s e d o n d e t e r m i n a n t s of s o l i d f o o d f e e d i n g p r a c t i c e s . T w o c o n c e p t u a l m o d e l s related to infant f e e d i n g that p r o v i d e a f r a m e w o r k o n t h e d e t e r m i n a n t s of infant f e e d i n g b e h a v i o r s (Lutter C K , 2 0 0 0 ) , a n d c o n c e p t u a l i z i n g nutrition p r o b l e m s a n d c a u s e s of c h i l d undernutrition ( A C C / S C N , 2 0 0 0 ) h a v e r e c e n t l y b e e n p u b l i s h e d . S i m i l a r to t h e f i n d i n g s of this study, the u n d e r l y i n g c a u s e s of infant f e e d i n g b e h a v i o r s a n d i n a d e q u a t e dietary intake d e s c r i b e d in t h e s e m o d e l s a r e m a t e r n a l c h o i c e s a n d c a r i n g p r a c t i c e s . A t a m o r e distant l e v e l , t h e s e m o d e l s identify t h e ' i n t e r m e d i a t e d e t e r m i n a n t s ' to m a t e r n a l c h o i c e s -  information  ( i n a d e q u a t e o r inappropriate), attitudes (discriminatory), s u p p o r t ( p h y s i c a l a n d s o c i a l ) a n d h u m a n r e s o u r c e s (quantity a n d quality). T h e p u r p o s e of t h e s e m o d e l s w a s to identify a n d better u n d e r s t a n d w h a t c a u s e s nutrition p r o b l e m s a n d w h a t o p t i o n s a r e m o d i f i a b l e . A s f o u n d in this r e s e a r c h , c o n d i t i o n s within the s o l i d f o o d f e e d i n g c o n t e x t (i.e., information, support) i m p a c t o n m o t h e r ' s f e e d i n g b e h a v i o r s , a n d t h e s e n e e d to b e fully u n d e r s t o o d in o r d e r to d e v e l o p effective e d u c a t i o n interventions that e n a b l e m o t h e r s to f e e d their infants effectively to p r e v e n t iron d e f i c i e n c y a n e m i a a n d iron d e p l e t i o n .  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 m o d e l of infant s o l i d f o o d f e e d i n g ( a d a p t e d f r o m G l a s e r , 1978) links t h e p l a u s i b l e r e l a t i o n s h i p s b e t w e e n t h e 5 t h e m e s identified in this r e s e a r c h to dietary a d e q u a c y . T h e s o l i d f o o d f e e d i n g p r o c e s s in F i g u r e 15 illustrates h o w the v a r i o u s c o n d i t i o n s within the f e e d i n g c o n t e x t i n f l u e n c e the m o t h e r ' s 'tailoring' p r a c t i c e s a n d h o w t h e s e p r a c t i c e s c o u l d influence s o l i d f o o d a c c e p t a n c e a n d c o n s u m p t i o n patterns (i.e., iron fortified c e r e a l ) a n d thus dietary a d e q u a c y . O n l y a f e w (3/12) of t h e m o t h e r s in this s t u d y a c h i e v e d t h e r e c o m m e n d e d f e e d i n g of 4 t a b l e s p o o n s of c e r e a l p e r d a y b y 6 m o n t h s of a g e , d e s p i t e the high e d u c a t i o n l e v e l of the s t u d y participants. F o r half of the m o t h e r s (6/12), t h e interview d a t a s u g g e s t e d that it took 3 m o n t h s b e f o r e t h e y a c h i e v e d routine f e e d i n g of % c u p of c e r e a l p e r d a y . C e r e a l c o n s u m p t i o n 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 d r y c e r e a l p e r d a y in 2 infants b y 7 m o n t h s of a g e . T h i s s u g g e s t s that m o t h e r s might benefit f r o m a better u n d e r s t a n d i n g of ' h o w ' to f e e d c e r e a l s d u r i n g the transition p e r i o d . W a l t e r et a l (1993) f o u n d that the liquid f e e d i n g p r a c t i c e s i n f l u e n c e d c e r e a l c o n s u m p t i o n . Infants f e d f o r m u l a c o n s u m e d a l m o s t 3 0 g of c e r e a l p e r d a y within 3 w e e k s of introduction, w h e r e a s it t o o k t h e b r e a s t - f e d infants 2 - 3 Vz m o n t h s to r e a c h i n t a k e s of 2 0 -  133  DISCUSSION  2 5 g m of c e r e a l p e r d a y . T h i s s u g g e s t s that m o t h e r s w h o b r e a s t - f e e d might h a v e m o r e difficulty with the transition p r o c e s s t h a n m o t h e r s w h o f e e d f o r m u l a . W a l t e r et a l (1993) a l s o s h o w e d that t h e c o n s u m p t i o n of iron-fortified c e r e a l significantly i n f l u e n c e d t h e iron s t a t u s of both b r e a s t - f e d infants a n d infants f e d low iron f o r m u l a . T h e s e a u t h o r s r e p o r t e d t h e  'cumulative' p e r c e n t a g e  of infants e x c l u d e d f r o m this s t u d y  b a s e d o n h e m o g l o b i n c o n c e n t r a t i o n s b e l o w 1 0 5 g/L. A s w o u l d b e e x p e c t e d , the g r o u p of infants f e d ironfortified f o r m u l a h a d t h e l o w e s t p e r c e n t of infants e x c l u d e d . B r e a s t - f e d infants w h o w e r e f e d iron-fortified c e r e a l w e r e c l e a r l y at a n a d v a n t a g e with 1 1 % IDA at 8 a n d 15 m o n t h s , c o m p a r e d to s i m i l a r infants not f e d a fortified product, with 1 5 % a n d 2 7 % IDA at both 8 a n d 15 m o n t h s , r e s p e c t i v e l y . T h e s t u d y b y Innis et a l , in 1 9 9 3 in V a n c o u v e r s i m i l a r l y f o u n d a b o u t 1 5 % I D A a m o n g 9 m o n t h o l d b r e a s t - f e d infants. A s l o w rate of i n c r e a s e in c e r e a l c o n s u m p t i o n to target l e v e l s m a y b e a n important d e t e r m i n a n t of iron s t a t u s , a n d this m a y b e e x p l a i n e d , in part, b y 'hoW the m o t h e r is 'tailoring' h e r f e e d i n g s t r a t e g i e s a n d t h u s achieving acceptance. F i g u r e 17 w a s d e v e l o p e d to illustrate v a r i a t i o n s a m o n g the infants' iron-fortified c e r e a l c o n s u m p t i o n patterns b e t w e e n 4 to 9 m o n t h s of a g e . S t a n d a r d i z e d tools (e.g., 3 - d a y f o o d r e c o r d s ) w e r e not u s e d to c o l l e c t the dietary d a t a s i n c e t h e f o c u s of the r e s e a r c h w a s e x p l o r a t o r y (i.e., t h e r e s e a r c h q u e s t i o n s identified h o w t h e m o t h e r s f e d their infants o v e r t i m e a n d w h y t h e y m a d e t h e c h o i c e s that t h e y did). L e s s e m p h a s i s w a s p l a c e d o n quantifying t h e f o o d s that w e r e f e d to infants. H o w e v e r , d e t a i l e d d a t a o n d i e t a r y i n t a k e w e r e c o l l e c t e d f r o m t h e f a c e - to - f a c e interviews a n d this d a t a is illustrated in a g r a p h i c format to p r o v i d e information o n dietary intake patterns o v e r t i m e . T h e s e c o n s u m p t i o n patterns were labeled as  'high arc' curve, 'S-curve', o r  a  'low flat' curve ( F i g u r e  17). A p p r o x i m a t e q u a n t i ti e s of  iron-fortified c e r e a l m o t h e r s ' f e d to their infants' w a s e x t r a p o l a t e d f r o m the m o t h e r s ' r e t r o s p e c t i v e d e s c r i p t i o n s a n d q u e s t i o n n a i r e r e s p o n s e s . T h e figure a i d s in identifying, theoretically, h o w different patterns of iron-fortified c e r e a l intake might contribute to dietary iron a d e q u a c y f r o m c e r e a l s . C l e a r l y , m o r e s y s t e m a t i c r e c o r d i n g s of quant it i e s of c e r e a l s a n d other s o l i d f o o d s f e d to infants f r o m 4 - 9 m o n t h s a r e n e e d e d to identify if, o r to w h a t d e g r e e t h e s e 3 c o n s u m p t i o n patterns reflect patterns that identify a n infant's risk for dietary iron i n a d e q u a c y .  134  DISCUSSION  3  4  5  6  7  8  9  10  Infant Age (months) Figure 17. T h e p l a u s i b l e v a r i a t i o n s in infants' iron-fortified c e r e a l c o n s u m p t i o n patterns from 4 to 9 m o n t h s of a g e . T h e a p p r o x i m a t e quantity of iron-fortified c e r e a l m o t h e r s ' f e d to their infants' w a s e x t r a p o l a t e d f r o m the m o t h e r s ' r e t r o s p e c t i v e d e s c r i p t i o n s of f o o d i n t a k e a n d q u e s t i o n n a i r e r e s p o n s e s . T h e 3 patterns a r e b a s e d o n i n - d e p t h interviews with a s a m p l e of 1 2 m o t h e r s . T h e figure a i d s in d e s c r i b i n g , theoretically, h o w c e r e a l c o n s u m p t i o n patterns s u c h a s t h e 'low flat curve' o r t h e first part of the 'S-curve' c o u l d i n f l u e n c e d i e t a r y iron i n a d e q u a c y in c o m p a r i s o n to t h e 'high arc curve' c o n s u m p t i o n pattern.  135  DISCUSSION In a d d i t i o n to t h e infant's p e r s o n a l c h a r a c t e r i s t i c s (i.e., t e m p e r a m e n t ) , f a c t o r s related to the m o t h e r a p p e a r to d e t e r m i n e f o o d a c c e p t a n c e to s o m e d e g r e e . T h i s s t u d y f o u n d variability in the n u m b e r a n d t y p e s of f e e d i n g s t r a t e g i e s u s e d b y m o t h e r s . T h e a v a i l a b l e d a t a s u g g e s t that the m o t h e r s ' s o l i d f o o d f e e d i n g b e h a v i o r s might i n f l u e n c e d i e t a r y iron 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 b y t h e 3 c u r v e s illustrated in F i g u r e 1 7 . T h e infant s o l i d f o o d f e e d i n g s t r a t e g i e s identified in this s t u d y that might h a v e determined the  high arc curve  i n c l u d e a p p r o p r i a t e m i x i n g strategies that f o c u s o n the infant's f o o d t a s t e  a n d texture p r e f e r e n c e s a n d s w i t c h i n g b r a n d s a n d t y p e s of c e r e a l to identify t h e o n e s t h e infant l i k e d . O t h e r s t r a t e g i e s i n c l u d e a d j u s t i n g t h e f e e d i n g m a n a g e m e n t or adjusting f e e d i n g routines s o that s o l i d f o o d s a r e f e d d u r i n g t h e d a y w h e n t h e infant is m o s t likely to b e hungry, f e e d i n g t h e infant d u r i n g f a m i l y m e a l t i m e s a n d s o c i a l i z i n g a r o u n d f o o d in o r d e r to p r o m o t e positive f e e d i n g d y n a m i c s . T h e s e s t r a t e g i e s fit the  S-curve pattern  a s w e l l , but t h e m o t h e r m a y h a v e t a k e n longer to learn ' h o w ' a n d 'what' to f e e d h e r  infant. F o r e x a m p l e , infant f o o d p r e f e r e n c e c u e s m a y h a v e b e e n m i s i n t e r p r e t e d ( d e l a y i n g the introduction of c e r e a l s ) o r l e a r n i n g h o w to m a n a g e d a i l y f e e d i n g routines m a y h a v e t a k e n l o n g e r . In addition, if the m o t h e r u s e d m i x i n g s t r a t e g i e s that t h e infant d i s l i k e d , p r o g r e s s o n getting t h e infant to a c c e p t w h a t 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 c u r v e , t h e  low flat curve,  s u g g e s t s that the infant h a d not  a c c e p t e d t h e c e r e a l s that w e r e o f f e r e d . T h e m o t h e r s in this c a s e might h a v e r e p e a t e d l y offered the s a m e c e r e a l that t h e infant d i s l i k e d , rather t h a n s w i t c h i n g to a n o t h e r t y p e o r b r a n d , or m i x i n g with other f o o d s to alter the t a s t e o r texture a c c o r d i n g to the infants' p r e f e r e n c e s . T h e s t r a t e g i e s that did not p r o m o t e ironfortified infant c e r e a l c o n s u m p t i o n i n c l u d e d r e p e a t e d l y offering d i s l i k e d f o o d a n d waiting for c e r e a l a c c e p t a n c e without tailoring the f e e d i n g s t r a t e g y to m e e t the infants' f o o d p r e f e r e n c e s . O t h e r s t r a t e g i e s that did not p r o m o t e c e r e a l a c c e p t a n c e i n c l u d e d s w i t c h i n g to fruits, v e g e t a b l e s a n d s n a c k f o o d s that t h e infant t h e n a c c e p t e d , o r u s i n g s t r a t e g i e s that might c a u s e n e g a t i v e f e e d i n g d y n a m i c s (distracting, s n e a k i n g o r c a m o u f l a g i n g f o o d s , stuffing o r f o r c i n g f o o d into the mouth). In s u m m a r y , b e h a v i o r a l f o c u s e d e d u c a t i o n interventions that a r e d e v e l o p e d with a n e m p h a s i s o n the t y p e s of s t r a t e g i e s that p r o m o t e iron-fortified c e r e a l a c c e p t a n c e q u i c k l y a r e l a c k i n g . Interventions that f o c u s o n m o d i f y i n g m o t h e r s s o l i d f o o d f e e d i n g p r a c t i c e s w o u l d i m p r o v e infant dietary iron intake w h i c h is c l e a r l y important to t h e p r e v e n t i o n of iron d e f i c i e n c y a n e m i a a n d iron d e p l e t i o n .  136  Further,  DISCUSSION  a n interventions that f o c u s e s o n ' h o w ' to f e e d a n infant c o u l d h a v e additional b e n e f i t s to the m o t h e r s u c h a s p r o v i d i n g a n i n c r e a s e d s e n s e of s e l f - e f f i c a c y a n d c o n f i d e n c e f e e d i n g s o l i d f o o d s d u r i n g a c o m p l e x transition p r o c e s s .  5.4.  Study limitations T r a n s f e r a b i l i t y is t h e t e r m u s e d , i n s t e a d of e x t e r n a l validity, in qualitative r e s e a r c h , to d e s c r i b e t h e  d e g r e e to w h i c h t h e r e s e a r c h findings c a n b e a p p l i e d in other settings or other g r o u p s of p e o p l e . T o m a x i m i z e transferability of results, r e s e a r c h e r s s t a t e h o w , u n d e r w h a t c o n d i t i o n s , a n d from w h o m d a t a w e r e c o l l e c t e d , t h u s a l l o w i n g the r e a d e r to a s s e s s t h e d e g r e e to w h i c h the findings might a p p l y to other c o n t e x t s o r a g e g r o u p s ( L i n c o l n Y . S . a n d G u b a E . G . 1 9 8 6 ) . ' T h i c k ' , d e t a i l e d d e s c r i p t i o n s of the interview d a t a a n d the participant c h a r a c t e r i s t i c s h a v e b e e n p r o v i d e d throughout t h e t h e s i s d o c u m e n t . T h i s a l l o w s the r e a d e r to j u d g e t h e transferability of t h e p r e s e n t s t u d y findings to other situations or p o p u l a t i o n s . T h i s s t u d y u s e d a qualitative r e s e a r c h a p p r o a c h to c a r e f u l l y s t u d y a s m a l l n u m b e r of participants. T h e s a m p l e is not r e p r e s e n t a t i v e of other p o p u l a t i o n s ( e . g . with different ethnic b a c k g r o u n d s , s o c i o - e c o n o m i c s t a t u s , o r lifestyles) s i n c e t h e s a m p l e w a s s m a l l a n d w a s not s e l e c t e d r a n d o m l y . T h e s a m p l e w a s s e l e c t e d f r o m 3 l o c a t i o n s in V a n c o u v e r , rather t h a n a s i n g l e site, to facilitate participation of m o t h e r s f r o m different l o c a t i o n s . H o w e v e r , the m o t h e r s w e r e relatively h o m o g e n e o u s , t h e y w e r e all of C a u c a s i a n b a c k g r o u n d , w e r e all h i g h l y e d u c a t e d a n d m o s t w e r e first time m o t h e r s . T h e s t u d y f i n d i n g s t h e r e f o r e , a r e limited to t h e p e r s p e c t i v e s of t h e s e participants a n d a r e difficult to c o m p a r e to o t h e r g r o u p s of m o t h e r s . M o s t of the p a r t i c i p a n t s w e r e i n t r o d u c e d to the r e s e a r c h student through a public health n u r s e . T h e n u r s e m a y h a v e s e l e c t e d m o t h e r s b e c a u s e of h e r p r e v i o u s e x p e r i e n c e with the m o t h e r ' s infant f e e d i n g p r a c t i c e s a n d c o n c e r n s . In this w a y , m o t h e r s m a y h a v e b e e n s e l e c t e d w h o h a d m o r e o r f e w e r difficulties f e e d i n g s o l i d f o o d s to t h e i r infants. T h e p r i m a r y m e t h o d of d a t a c o l l e c t i o n w a s in - d e p t h interviews. T h e r e s e a r c h student h a d prior training in i n t e r v i e w i n g t e c h n i q u e s a n d u n d e r s t o o d t h e i m p o r t a n c e of 'listening' to the m o t h e r s ' s t o r i e s , not directing t h e m . In this w a y , t h r o u g h e x p e r i e n c e a n d a w a r e n e s s , the potential of ' l e a d i n g ' participant r e s p o n s e s w a s d e c r e a s e d . T h e i n t e r v i e w s a l s o f o l l o w e d a s e m i - structured interview g u i d e . T h e interviews s t a r t e d with b r o a d , o p e n - e n d e d q u e s t i o n s that f o c u s e d the interview onto the g e n e r a l t o p i c .  137  DISCUSSION  T h i s a l l o w e d the p a r t i c i p a n t s to d e s c r i b e or identify infant s o l i d f o o d f e e d i n g i s s u e s that w e r e important to t h e m . H o w e v e r , t h e g e n e r a l t o p i c f o c u s e d o n infant s o l i d f o o d f e e d i n g a n d t h u s this e m p h a s i s w a s evident f r o m the d a t a in t h e transcripts o n f o o d , f e e d i n g , a n d nutrition a n d l e s s e m p h a s i s o n e n v i r o n m e n t a l i s s u e s that m a y i m p a c t m o t h e r s ' f e e d i n g c h o i c e s . T h u s , r e g a r d l e s s of the p r o c e d u r e s in p l a c e to d e c r e a s e l e a d i n g r e s p o n s e s , the r e s e a r c h f o c u s itself a n d the g r a d u a t e s t u d e n t ' s nutrition b a c k g r o u n d potentially b i a s e d t h e transcript d a t a t o w a r d s t h e s e i s s u e s . Further, the g r a d u a t e student h a s y o u n g c h i l d r e n a n d t h u s h a s e x t e n s i v e e x p e r t i s e in infant f e e d i n g f r o m f e e d i n g h e r o w n infants. T h e s e p e r s o n a l e x p e r i e n c e s a i d e d in e s t a b l i s h i n g rapport with t h e participants q u i c k l y a s well a s a i d e d d a t a interpretation.  H o w e v e r , p e r s o n a l b i a s e s f r o m the r e s e a r c h e r ' s p r e c o n c e i v e d ' i d e a s ' a b o u t ' f e e d i n g ' m a y  h a v e i n f l u e n c e d t h e d a t a interpretations (i.e., difficulties with c e r e a l a c c e p t a n c e ) . It is important to a c k n o w l e d g e p e r s o n a l v a l u e s a n d a s s u m p t i o n s that might b i a s interpretations but a l s o bring a u n i q u e v i e w to t h e d a t a c o l l e c t i o n a n d a n a l y s i s . P e r s o n a l e x p e r i e n c e s f e e d i n g c h i l d r e n solid f o o d s a n d b r e a s t - f e e d i n g b e y o n d 9 m o n t h s of a g e e n h a n c e d the r e s e a r c h e r ' s a w a r e n e s s , k n o w l e d g e a n d sensitivity to m a n y of the c h a l l e n g e s , d e c i s i o n s a n d i s s u e s e n c o u n t e r e d b y the m o t h e r s in this s t u d y d u r i n g t h e transition p r o c e s s . H o w e v e r , d u e to t h e s e p r e v i o u s e x p e r i e n c e s certain b i a s e s m a y h a v e i n f l u e n c e d d a t a interpretation.  P e r s o n a l b i a s e s s u c h a s the r e s e a r c h e r ' s v a l u e s that a r e c e n t e r e d  a r o u n d the i m p o r t a n c e of nutrition to infant h e a l t h a n d a c h i e v e m e n t a n d the critical role of the m o t h e r o r p r i m a r y c a r e g i v e r in t h e infant f e e d i n g p r o c e s s m a y h a v e s h a p e the w a y that t h e d a t a w e r e v i e w e d a n d u n d e r s t o o d . T h e r e s e a r c h e r a c k n o w l e d g e s that w o m e n ' s e x p e r i e n c e s a n d their ' v o i c e ' r e p r e s e n t s 'expert' k n o w l e d g e of t h e i n t r i c a c i e s of d a y to d a y tacit k n o w l e d g e a n d h e n c e a s s u m e d that t h e s o l i d f o o d f e e d i n g p r o c e s s d u r i n g t h e transition p e r i o d w o u l d b e c o m p l e x . T h u s , qualitative r e s e a r c h m e t h o d s w e r e c h o s e n to s t u d y this c o m p l e x i t y . T h e r e s e a r c h e r a s s u m e d that t h e f e e d i n g p r a c t i c e s a m o n g m o t h e r s w o u l d differ b e c a u s e f e e d i n g p r a c t i c e s w o u l d b e c l o s e l y linked to e a c h m o t h e r ' s u n i q u e p e r s o n a l a n d e n v i r o n m e n t a l c o n t e x t . T h e r e s e a r c h e r ' s role a s t h e p r i m a r y d a t a c o l l e c t i o n a n d a n a l y s i s i n s t r u m e n t is t h u s , to u n d e r s t a n d h o w t h e s e e x p e r i e n c e s might b i a s t h e d a t a interpretations. T h e credibility of the r e s e a r c h interpretations w a s e n h a n c e d t h r o u g h the following p r o c e d u r e s . A reflexive j o u r n a l w a s kept t h r o u g h o u t t h e s t u d y that i n c l u d e d a d e t a i l e d d i a l o g u e a b o u t the m e a n i n g s of the d a t a that w e r e b e i n g a n a l y z e d . In - d e p t h i n t e r v i e w s w e r e c o m p l e t e d with 12 m o t h e r s . T h e in depth 138  DISCUSSION  interviews, the a n a l y s i s p r o c e d u r e s a n d p r o l o n g e d , i n t e n s i v e c o n t a c t with t h e field of s t u d y facilitated the d e v e l o p m e n t of t h e c o n c e p t u a l d e n s i t y of the f i n d i n g s of this study. A potential limitation of the s t u d y w a s that the f i n d i n g s a r e d e p e n d e n t o n t h e participants d i s c u s s i n g their a c t u a l b e l i e f s a n d p r a c t i c e s a n d not w h a t t h e y m a y p e r c e i v e that t h e r e s e a r c h e r w a n t s to h e a r . T h e participants in this s t u d y m a y h a v e c h o s e n , or not, to i n c l u d e details o n the difficulties t h e y e n c o u n t e r e d , p r a c t i c e s or b e h a v i o r s that m a y b e c o n s i d e r e d i n a p p r o p r i a t e o r their p e r s o n a l f e e l i n g s (i.e., negative) a b o u t health p r o f e s s i o n a l s ' p r a c t i c e s . H o w e v e r , t h e m o t h e r s s e e m e d v e r y c o m f o r t a b l e s h a r i n g their e x p e r i e n c e s f e e d i n g their infants a n d o p e n l y reflected o n t h e p r a c t i c e s that did not w o r k a s w e l l a s o t h e r s that d i d . T h e participants a p p e a r e d to b e c o m f o r t a b l e with t h e r e s e a r c h student, a n d this m a y h a v e b e e n d u e to the fact that t h e y all k n e w that t h e r e s e a r c h s t u d e n t h a d c h i l d r e n a n d w e r e i n t e r e s t e d in her f e e d i n g e x p e r i e n c e s a s w e l l . A l t h o u g h t h e m o t h e r s f r e e l y d i s c u s s e d h o w t h e y f e d their i n f a n t s , t h e y a p p e a r e d l e s s o p e n a b o u t their f e e l i n g s a b o u t t h e role of t h e ' e x p e r t s ' (i.e., health c a r e p r o f e s s i o n a l s ) , in the context of the s o l i d f o o d f e e d i n g p r o c e s s . T h i s w a s p o s s i b l y d u e to their p e r c e p t i o n s a b o u t t h e confidentiality of t h e d a t a . A d e t a i l e d d e s c r i p t i o n of h o w t h e a n a l y s i s e v o l v e d , with t h e c o d i n g p r o c e d u r e s , g i v e s insight into the quality (dependability) of d a t a m a n a g e m e n t o r g a n i z a t i o n a n d a n a l y s i s p r o c e d u r e s . A s e r i e s of documentation procedures were followed ( L C , IISS,  MSa*, C C S S  a n d integrative d i s p l a y s ) to aid in t h e  d a t a o r g a n i z a t i o n , t h e a n a l y s i s p r o c e d u r e s a n d t h e d a t a interpretations. T h e s y s t e m a t i c d a t a c o l l e c t i o n , transcription a n d a n a l y s i s p r o c e d u r e s u s e d in this s t u d y a d d to the quality of a n a l y s i s a c h i e v e d (i.e. within a n d a c r o s s c a s e a n a l y s i s ) ( R o d g e r s a n d C o w l e s , 1 9 9 3 ) . T h e interpretive a n a l y s i s p r o c e s s w a s iterative in that it i n v o l v e d t h e writing of s u m m a r i e s a n d t h e n returning to t h e original d a t a s o u r c e to verify t h e e v o l v i n g c o n c e p t s , c a t e g o r i e s a n d t h e m e s within t h e original context. H o w e v e r , this is the r e s e a r c h s t u d e n t ' s first m a j o r r e s e a r c h project a n d t h u s t h e d a t a m a n a g e m e n t a n d d a t a a n a l y s i s m a y reflect this l a c k of e x p e r i e n c e . T h i s is a limitation s i n c e , in qualitative r e s e a r c h , the d a t a a n a l y s i s tool is the r e s e a r c h e r . S t r a u s s a n d C o r b i n (1990) s t a t e that " t h e o r e t i c a l sensitivity refers to t h e attribute of h a v i n g insight, t h e ability to g i v e m e a n i n g to d a t a , t h e c a p a c i t y to u n d e r s t a n d , a n d c a p a b i l i t y to s e p a r a t e the pertinent f r o m that w h i c h isn't. It is t h e o r e t i c a l sensitivity that a l l o w s o n e to d e v e l o p a theory that is g r o u n d e d , c o n c e p t u a l l y d e n s e , a n d well i n t e g r a t e d " . T h e s e a u t h o r s s u g g e s t 4 s o u r c e s that p r o m o t e 'theoretical sensitivity"; the literature, p r o f e s s i o n a l e x p e r i e n c e , p e r s o n a l e x p e r i e n c e a n d the ability to b a l a n c e b e t w e e n creativity a n d s c i e n c e . T h e interpretation of the d a t a is a l s o limited by the  139  DISCUSSION  g r a d u a t e s t u d e n t ' s b r e a d t h of k n o w l e d g e in t h e field of qualitative d a t a a n a l y s i s m e t h o d s a n d p e r s p e c t i v e s . T h e d a t a interpretations w o u l d b e different if a feminist p e r s p e c t i v e w a s u s e d in t h e a p p r o a c h to d a t a a n a l y s i s . A l t e r n a t e l y , a d i s c o u r s e a n a l y s i s w o u l d h a v e identified different, yet important, t h e m e s within the t r a n s c r i p t s . T h i s s t u d y u s e d g r o u n d e d t h e o r y d a t a a n a l y s i s p r o c e d u r e s in o r d e r to identify ' p r o c e s s ' within t h e d a t a ; h o w e v e r , it is a c k n o w l e d g e d that other p e r s p e c t i v e s m a y h a v e b e e n v a l u a b l e for u n d e r s t a n d i n g f a c t o r s that d e t e r m i n e m o t h e r ' s s o l i d f o o d f e e d i n g c h o i c e s . A further limitation of this s t u d y w a s that t h e participants w e r e not g i v e n the opportunity to p r o v i d e f e e d b a c k o n the d a t a interpretations.  F u t u r e r e s e a r c h n e e d s to a d d r e s s this i s s u e . T h e interpretations of  t h e transcript d a t a w e r e , t h e r e f o r e , not v e r i f i e d with t h e p a r t i c i p a n t s . Further, t h e interview d a t a c o l l e c t i o n w a s c o m p l e t e d b e f o r e t h e a n a l y s i s w a s s t a r t e d . H o w e v e r , this m a y not b e a s important in this s t u d y a s in a larger s t u d y w h e r e ' t h e o r e t i c a l ' s a m p l i n g of participants for s u b s e q u e n t interviews a r e b a s e d o n t h e findings of the p r e v i o u s i n t e r v i e w s . A l t h o u g h this s t u d y u s e d 2 m e t h o d s of d a t a c o l l e c t i o n (in-depth s e m i structured interview a n d q u e s t i o n n a i r e ) to o b t a i n information, the q u e s t i o n n a i r e w a s c o m p l e t e d b y o n l y 9 of the 12 p a r t i c i p a n t s . S o m e q u e s t i o n s in the q u e s t i o n n a i r e h a d two m e a n i n g s a n d t h u s , t h e formatting of the q u e s t i o n s r e q u i r e s r e v i s i o n s . S o m e d a t a w a s m i s s e d in t h e s p r e a d s h e e t f o r m a t d u e to the c o m p l e x i t y of the a n s w e r format (i.e., f r e q u e n c y of f e e d i n g c e r e a l s ) a n d thus r e v i s i o n s to simplify t h e format a r e needed. E x t e r n a l c h e c k s w e r e c o m p l e t e d d u r i n g t h e a n a l y s i s of d a t a b y a s k i n g p r o f e s s i o n a l p e e r s ( S u p e r v i s o r y C o m m i t t e e ) to r e a d drafts of s t u d y reports. T h i s a i d e d in ' b a l a n c i n g ' v i e w p o i n t s o n c o n c e p t s , c a t e g o r i e s , a n d t h e r e l a t i o n s h i p s that w e r e identified. T h e f e e d b a c k w a s u s e d to r e c o n s t r u c t interpretations. H o w e v e r , the c o m m i t t e e c o n s i s t e d of w o m e n , d a t a interpretation f e e d b a c k m a y h a v e differed if the c o m m i t t e e h a d b e e n c o m p o s e d of m e n a n d w o m e n .  A further limitation of this s t u d y w a s  that t h e f i n d i n g s w e r e not p r e s e n t e d to t h e health p r o f e s s i o n a l s a n d m o t h e r s at the recruitment s i t e s . T h i s p r o c e s s w o u l d h a v e a i d e d in s h a r i n g t h e f i n d i n g s with this g r o u p a n d verifying t h e interpretations a n d their r e l e v a n c e to the m o t h e r s in t h e s e g r o u p s . In o r d e r to k e e p t h e a n a l y s i s b r o a d to identify c o n t e x t u a l factors o r i n f l u e n c e s o n the s o l i d f o o d f e e d i n g p r o c e s s , n e g a t i v e c a s e s of s i t u a t i o n s , e v e n t s , or e x p e r i e n c e s w e r e identified t h r o u g h o u t t h e a n a l y s i s p r o c e s s . F o r e x a m p l e , 14 f e e d i n g s t r a t e g i e s w e r e identified, rather t h a n just a f e w , s u g g e s t i n g a n  140  DISCUSSION  i n t e n s e a n a l y s i s of t h e d a t a to identify the m o s t v a r i a t i o n s p o s s i b l e . H o w e v e r , qualitative d a t a a n a l y s i s is r e c o g n i z e d a s a d e m a n d i n g c o g n i t i v e t a s k , t h u s the r e s e a r c h s t u d e n t s level of 'fatigue' m u s t b e a c k n o w l e d g e d a s influencing t h e a n a l y s i s o u t c o m e . T h e confirmability criteria a i m s to e v a l u a t e the r e s e a r c h product, the d a t a , t h e findings, interpretations, a n d r e c o m m e n d a t i o n s . T h e d a t a o b t a i n e d f r o m the m o t h e r s in this s t u d y w a s v e r y 'rich' a n d the s t u d y f i n d i n g s reflect this. T h e results of this s t u d y c a n b e j u d g e d in light of the n u m e r o u s p r o c e d u r e s f o l l o w e d to p r o m o t e the b e s t d a t a m a n a g e m e n t , d a t a a n a l y s i s , a n d interpretive integration p o s s i b l e . H o w e v e r , t h e r e c o m m e n d a t i o n s e m p h a s i z e t h e n e e d to v a l i d a t e the t h e m e s a n d their p l a u s i b l e r e l a t i o n s h i p s in future s t u d i e s with larger s a m p l e s i z e s of m o t h e r s with v a r i e d f e e d i n g p r a c t i c e s a n d e x p e r i e n c e s (breast a n d b o t t l e - f e e d i n g , m o r e t h a n o n e child) a n d b a c k g r o u n d s (ethnic, s o c i o - e c o n o m i c , a n d lifestyle). A l t h o u g h this is o n l y a s m a l l s t u d y of m o t h e r ' s infant f e e d i n g b e h a v i o r s , the p u r p o s e w a s to investigate b e h a v i o r s in-depth in a natural s e t t i n g . T h i s r e s e a r c h h a s r a i s e d s o m e important q u e s t i o n s r e g a r d i n g dietary iron a d e q u a c y a n d the p r e v e n t i o n of iron d e f i c i e n c y a n e m i a a n d iron d e p l e t i o n in a natural setting. T h i s s t u d y h a s a l s o p r o v i d e d a c o n c e p t u a l f r a m e w o r k of s o l i d f o o d f e e d i n g during t h e transition p r o c e s s that c o u l d b e u s e d to g u i d e future r e s e a r c h a n d p r a c t i c e .  5.5  Conclusions. S o l i d f o o d f e e d i n g is c o m p l e x a n d i n v o l v e s i n t e r a c t i o n s at m a n y l e v e l s . T h e m o t h e r ' s s o l i d f o o d  f e e d i n g p r a c t i c e s a r e d e t e r m i n e d , in part, b y t h e infant's f e e d i n g r e s p o n s e s , t h e m o t h e r ' s p e r c e p t i o n s of infant f o o d n e e d s a n d t h e m o t h e r ' s k n o w l e d g e a n d s k i l l s . P r a c t i c e s n e e d to b e a p p r o p r i a t e to m e e t the infant's e v o l v i n g nutritional r e q u i r e m e n t s , e s p e c i a l l y iron n e e d s , d u r i n g the transition p e r i o d (4 to 9 m o n t h s ) . It is k n o w n that b y 9 m o n t h s of a g e infants w h o a r e not bottle-fed with iron-fortified f o r m u l a a r e at high risk for iron d e f i c i e n c y a n e m i a a n d low iron s t o r e s . D i e t a r y iron f r o m c o m p l e m e n t a r y f o o d s is e s s e n t i a l to p r e v e n t iron d e f i c i e n c y a n e m i a a n d iron d e p l e t i o n b y 9 - 12 m o n t h s of a g e , h o w e v e r , the content a n d bioavailability of iron in s o l i d f o o d s o f f e r e d d u r i n g the transition p e r i o d is low. T h e r e f o r e , it is critical that m o t h e r s l e a r n ' h o w to f e e d s o l i d f o o d s a p p r o p r i a t e l y , if the infant's iron s t o r e s a r e to b e 1  m a i n t a i n e d d u r i n g this nutritionally ' v u l n e r a b l e ' p e r i o d .  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. T h e 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. T h e most important aspect of this research is the discovery of 5 themes that were identified as central to the solid food feeding process. T h e s e 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. T h e second model links dietary iron adequacy to the plausible relationships that were identified and represented in the 5 themes. T h e s e 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. T h e 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. T h e 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. T h e 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  F U T U R E DIRECTIONS  Chapter VI  6.1.  1.  Future directions for research  F u t u r e s t u d i e s s h o u l d c o n t i n u e to e x p l o r e t h e t h e m e s , m o d e l s a n d f r a m e w o r k identified a n d d e v e l o p e d in t h e p r e s e n t study. R e s e a r c h u s i n g f o c u s g r o u p s is n e e d e d to verify the p r e s e n t f i n d i n g s in a l a r g e r m o r e h e t e r o g e n e o u s s t u d y s a m p l e .  2.  F u t u r e s t u d i e s with a larger s a m p l e of m o t h e r s c o u l d b e u n d e r t a k e n to e x a m i n e s o l i d f o o d f e e d i n g s t r a t e g i e s that c o u l d potentially p r o m o t e t h e c o n s u m p t i o n of iron-fortified c e r e a l in i n c r e a s e d q u a n t i t i e s , p r o m o t e a f a s t e r rate of c e r e a l a c c e p t a n c e a n d p r o m o t e m a x i m a l potential for high iron a b s o r p t i o n ( s u c h a s the p r e p a r a t i o n m e t h o d ) .  3.  A n e d u c a t i o n intervention c o u l d b e d e s i g n e d that w o u l d p r o m o t e m o t h e r s ' u n d e r s t a n d i n g of h o w to f e e d s o l i d f o o d s d u r i n g t h e transition p e r i o d , that w o u l d p r o m o t e s t r a t e g i e s that i n c r e a s e t h e c o n s u m p t i o n of dietary iron f r o m iron-fortified infant c e r e a l s a n d that m o n i t o r s infant iron s t a t u s to d e t e r m i n e t h e e f f i c a c y of the e d u c a t i o n intervention.  4.  F u t u r e s t u d i e s c o u l d u s e the m o d e l s d e v e l o p e d f r o m the findings in the p r e s e n t s t u d y to g u i d e b r o a d e r r e s e a r c h s u c h a s identifying t h e i m p o r t a n c e of t h e m o t h e r ' s s e l f - e f f i c a c y to s o l i d f o o d f e e d i n g outcomes.  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). 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J Pediatr 1 9 9 0 ;  117: S181-9  S a w c h u k P , R a u l i u k 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 , S t a r r M : Infant nutrition p r o g r a m : i r o n - d e f i c i e n c y a n e m i a in a First N a t i o n s c o m m u n i t y . 96 Curcumpolar Health 1 9 9 6 ; 1 8 9 - 1 9 3 S c a m m o n R E , D o y l e L O : O b s e r v a t i o n s o n t h e c a p a c i t y of t h e s t o m a c h in t h e first t e n d a y s of p o s t n a t a l life. Am J Dis Child 1 9 9 0 ; 5 1 6 - 3 8  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 L J , Innis S M : 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 D M , 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 P J , 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 H J , 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 E A , Caulfield L A , Harris S B : 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: G e n e v a , Switzerland, 1981 W H O / U N I C E F . Protecting, promoting and supporting breast-feeding: the special role of maternity services. G e n e v a , Switzerland: World Health Organization/ U N I C E F , 1989 Williams PL, Innis S M , Vogel A M P , Stephen L J : 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 A M P : 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 Q u e b e c . Can Med Assoc J 2000; 162(3): 323-326 World Health Organization. T h e quantity and quality of breast milk. Report of the W H O collaborative study on breastfeeding. G e n e v a . 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: T h e Canadian Public Health Association 1983. Yeung DL, Pennell M D , 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 : T h e 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  I— OJ  'ra ,  Is §cn  cn T3 3  s  "3  >- KJ tl  S g -  I  C«  X QO  1 1  ' 3 -f3 o? O TI  n 2  re Ol o a o 35 o E 8 £ o-S •a in oi S 3 T3  o> in •—  <2  ,  &S'  J  Q  —]  ™ o.  o  £ in  ~  O  Tl  to  t/j ^ .QJ n3  * o « -a a •» o  3 C N • oj §-° S . CB N" * c cn a. " 3CT ; 3re— -fi -a ™ 10 uU OI 3 T3 « — — c -—• Si fi CM £ TJo x ra _ _ ~ TJ 01 C 9) o > .2 m MJin cn H S P ~ 1 0  Is u & 8  x  OJ •a ra D. TJ c  cs "ra  v  •El 'X!I T3a cn C oi re cn  re -a E  X  g ra 01  . s cn  T3  a l l  O M) re cn C re E '>> <" Oi  ra TI ra x c S E *—' o is d '8 c | c O sE > o v*- do ra re & Oi X < — 1W > >. o  ra 01  oi  o  Oi  T3  IEI  ill  Oi 60 • H i O O 60 c  a2 0 u o> v C cn ; oi '5 re 01 cn C bO a. S 3, 3 •C^cn re ^ cno> a- " 2 8- re g- 01 •*sra o 01 Cu re no .. x Oi 2 <B M  1  CS  B.^i I j JCj cn- O £ 're  r-'S  t:  > -a o .. o S QJ &  O O  *  (U  .5 S3*  2 -a sE * J B  -^ g§ -a | g  QJ CO  Cm  -2  H &ra  re ra re  o _. E c  o  E ^1 2' re £ I,  Is  O oi cn _ 3 ra oi  3  . o xi  U  cn  ra ra  E  w re "r"  Do S 5 ~a E  o  Oi  , S 60 T3  .2  Oi  o  a.  s. cnra  1  oi * ;  60 C  •eSs -ac  i i  ra  3 g  c  c  60  aj  .3o  m  0) u  X  X  60 &0 OJ 01  I -  s  Ji  ra  O c > 'So  ra o  QJ „•  T3  c  S3 C ra ra C cn . 2 ra cn oi  -c  o ^ . •a 5 to  3  o  o -a c  bf)t^  .a i >- OJ ^ TJ tn» 3 i=  «  8 c  OJ X  CN  O)  o  >• • *  CD  £S  S  cn o» tn  cu  it 6  is c  Oi  P  ^3  xi  .s  3  «  oi cn CQ  0=  ^>ra g "33  5-  ui g re O.  •3  6b  "O g  - 3 O 01 cn re re *s  i2 S c 2 12 2 J2 c  I  5 - » ra  m  8^1 6  a u . g r Oi . . X X .3 > cn u _ * u o QJ; ^ _ oi > c oIH g MM " .S-S - T J cn >. o ^ra u D- 'ra•  a s  cn •a 6  « »|-S  •S «  u  J ^ X  > >, re  £3  •2 E  3 o &" S j S 8>S -a E o c 3 o <• > 0-recn \o ca  154  c  OJ |_, • — 60 3 >. Oi o x  8.2  rT -i 2  H  a  10  ii  x 3 E d. c. ra•Ca re cn 1 3 .S ^ x  O » 3  g T3 £c o- g Oi  §=3s •I c  c  Tf  s  U ra  1-S 5 1  Ii  x; a oi oi SB D--33-33 o Z  8  APPENDIX D  Recruitment Checklist Determinants of Weaning Practices Among Breast-feeding and Formulafeeding Mothers  Participant Code:  • • • •  Mother's name Infant's name Birth date: Age:. Gestation (wks) _ _ _ _ _  Phone  Does participant meet the following criteria? O O O O )  Caucasian mother who is breast-feeding or formula-feeding. Infant is 4-12 months of age. Mother is living in Vancouver, B.C. 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  JZ  -~ £ o CD  JC  £  CD  c c >- 9 •  -o OJ  CO ZJ  i-  5?  Q.  CD  C  Q. o •-•  5  ~  -  O  '£ a)  -o J3  O  c  Z UJ  O o  P 5? 55 g o  •S «o 3  O  CD  ^  CO  O m CD CD O CD ft O CD •*= co o c  u  CO  +•>  CD  - 13  cr co  ^  CD  S *  }2  £  c o  >  S - ~ O Q . CO  « o §  .«2  to « co-  a. CO  o  ^  x:  "&0  c  CD  ai  § g S  £1*  O ~ c  CD CO  CD  • • • •  TD  S.r> g » g o  tE CO  CD  s S.S  E V CD  Q CD  55 55 S  S -  CD •*-» CO  «S  8'*  7- O ©  O  O  '._] !c  CO O  O =  CD O OJ L L  >  E -a o c *tto .— TD  ~ o  >» ro  c .&8 E o >s  55 cCoD -eco  .E £  E  < 158  TD  c a . co  o  CO  o =  z  CD  CO  0)  < C  CO Q. O  CDJtt CD CO CO  c  "t:  CO Q_  CD CO CO  _  CO  O  CO CD  00  APPENDIX E  o < > /  _ro  £  c o o GO  (/>  to  c  (0  CD  E .o  o N O  0) O)(0  ° r:  c  TJ C  > O  CD  Q.  x:  0)  a> CD CD ; i_ x> C O CD  •*->  " C </> Q.  2™  Q.O Q . (0  c Ui CO  o) a) co - q CL =  <£- i— x - CD  £  >  tn Qi  ^ 2 E E  o a.  CO  O  O  X -o  (A CO  si  CQ i  <  to CD  > a ) >>  •  o. u V.  .  Xi CO X) 1—  o > %  c-  O  z  • co a> > -  CL  CN  3  , „  O >»  Q. O  CD C  a)  o  z  I -•—'  GO  CO o CD  3 o c o CD X3 <  "c 3 o E  CO  -Q  • CO  CD  >  T3 C CD x:  o* c  C Q . CO 2  D  3  2 E « =•  <  159  CD  o o  x:  o  •  £  £ (D O) CD . £ CD [_ CD CD CL  CO  3  CO  TJ | CD 0) TD *7 0> "cO C CO CD  co  V.  o o  c  0)  E  CD <  o TJ co 0- c o .CO  E w  co  N  T3  CD  GO  E  <  < o o a  ffi 3  CD  0) (A C  i—  -Q  i  n  cr x: F—  o a c/> a> a> ro a>  co TJ T3 CD CD ,CD  — ' co  •Fi ^CO _^ a. « T3  Q.  2  i_  z  "fo  CD  CD a.  •o c  CO T3  E £  o  0)  * 3 J ^  Ic  •  CO 00  yo  3 o >» c o CO 3 o  >>o-  CO ^ TD .C CD "O  E  si§  ca  • 00 CD  <D CD CO  "(0 x: CO  of .a> >>  APPENDIX E  tn _i S  o or u. CO  O  5  Q.  C3 2  ill P  o c ro O  'ro •c  Z a z  UJ LU  m  >-  CO < m  to <  I  to  X Iz  o s I  o  5  a: m  to" LU  a  1. Number of feeds/day  a z <  Baby Eats  to  You Use  BRANDS AMOUNTS  I  • • •  • •  • • •  •  • • •  • • • • • • • • •  • • •  • • •  • • •  • • •  • • •  • • • • • •  • • • • • • • • •  • •  • • •  • • •  • • •  • • •  • • •  • • • •  • • •  • • •  • • •  • • •  • • •  • • • • • •  • • • •  • • •  2. Minutes/feed  • • • •  0"f  o l-  i-  (N  n  f «  • • • • • • • • •  • • • •  • • • •  • • •  ID  to  UJ I-  p to  f  ) c. Juice (dilution  b. Goats Milk  Other:  a. Soy Milk (not formula)  d. Skim or c. 1%  2%  IN HOSPITAL  i  O  •  • • •  • • •  • • •  NEVER USED  *  b.  LU  a. Whole milk  TJ 2 K  Q. XI O CO  a. Regular (low iron)  «  ~ >  Breast-Milk:  •° =1l ^ ^ t o s l  Infant Formula:  If)  a> o <»  Cows' Milk:  o  TJ C  c. Soy-based formula  ro  b. Formula with iron (fortified)..  O)  •  • • •  • • •  • • •  160  APPENDIX E  CD CD  3  O  t_ C D  3  o  CD  E  oD C CD CD XT GO  « f  JO CD oX> CD l_ i_ CD CL o C >. 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E  to  c  CU  x> "O °  E  O)  in  a>  ra c  3  ^£ 2  -g  in ca  ca  .  0)  C».c cu 3= CD LL O  3  2  c  0  x: Ti  > co > a.  co  CO  ra CD V—  CD O X J in CD T J a> CD .CD  JC ra  >% x> ro  X)  is >,  CD  X)  ro X)  II  ss  CD  E  raTJ CD £ Xt  •° a?  ra £ CD • O -~  ra >< X)  ro ra  in  >. >> E E  o  o  ro "ro £ £  CD CD  o  o  0  3 5=  C  c  SZ »  3  o >» o  TJ  ro  TJ TJ CD CD CU CD  8 2  * - XJ  I  162  in i  o to 0 o c  co  • WHICH MONTHS HAS BABY BEEN EATING FOODS ON LIST?  APPENDIX E  • • • • • • • • • • • •  • • • • • • • • is?} • • Ill • •  1  • • • • • • • • • • • •  • • • • • • • • • • • •  • • • • • • • • • • • •  • • • • • • • • • • • •  • • • • • • • • • • • •  • • • • • • • • • • • •  • • • • • • • • • • •