“Hidden Realities” Influencing Parent’s Feeding Choices and Behaviours

Key messages:

• Nutrition during the first 1000 days has critical influence on the immediate and long-term
physical and cognitive development of infants.
• Infant feeding is a large component of parenting that encompasses the social, cultural, and economic structure of a parent’s life.
• Education and support from health care providers that empowers parents to adopt recommended infant feeding guidance provides an unmet opportunity within nutrition education.

Nutrition during the first 1000 days, spanning from conception to age 24 months, has critical influence on the immediate and long-term physical and cognitive development of infants. Significant progress with improved infant feeding and nutrition has been realized through nutrition education efforts. However, childhood growth faltering, as evident by the number of children at both the lower and upper percentiles of the World Health
Organization growth standards, remains a significant public health concern across the globe1. The period from birth through the first 12 months characterizes a unique time when parents or caregivers make essentially all feeding decisions about what and how their infant is offered food2. Although the definition of a modern family is changing, parents are currently described as the main caregivers of children in the home. From a human development perspective, parenting has been described as a means of training and promoting the physical health and safety, as well as emotional, behavioral, and cognitive competence of children to meet demands within their culture in which they are to survive and thrive3. As early nutrition and feeding is an integral component of parenting that encompasses the social, cultural, and economic structure of a parent’s life4, understanding the current modifiable determinants influencing parents’ feeding choices and behaviors is essential in providing support and education. A recent systematic review5 summarizes 73 qualitative studies published between 2015 and 2019 related to parent attitudes, beliefs, and perceptions regarding infant feeding (Figure 1). Four major themes are identified:
• Breastfeeding is best for an infant
• Distinct attitudes, beliefs, and perceptions of mothers that breastfeed, and those that could not or chose not to breastfeed, are evident
• Infant feeding behaviors are influenced by the socio-cultural environment of the family
• Parent’s expectations of education and support addressing their personal infant feeding choices from health care providers are not always met 

Results from this review identified that parents predominately agree that breastfeeding is the best way to feed infants. As similar to conclusions from older systematic reviews, recent mothers described breastfeeding in terms of their “perceived expectations,
compared to the reality they experienced.” Similarly, a dichotomous desire to be a good/perfect mother (compared to feeding approaches perceived inconsistent with “good mothering”)6,7 was realized in the current review.

Although some large studies have reported that mothers often decide about infant feeding on their own initiative8, previous qualitative literature reviews have concluded that family and cultural practices are strong influences on infant feeding behaviors6,7, 9,10. The results expand upon previous themes with specific new findings. In particular,
parents report a desire, and have expectations, that they will be offered factual education related to their individual and personal infant feeding choices, provided with sensitivity, in a non-judgmental manner.


Education and support that addresses family and cultural priorities and empowers parents to adopt recommended infant feeding guidance, while preventing or addressing
internalized feelings of shame or guilt, provides an unmet opportunity within nutrition education5.

References
1. NCD Risk Factor Collaboration (NCD-RisC)., Worldwide trends in body-mass index,
underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults. Lancet 2017, 390 (10113), 2627-2642.
2. Spyreli, E.; McKinley, M. C.; Allen-Walker, V.; Tully, L.; Woodside, J. V.; Kelly, C.; Dean, M., “The One Time You Have Control over What They Eat”: A Qualitative Exploration of Mothers’ Practices to Establish Healthy Eating Behaviours during Weaning. Nutrients 2019, 11 (3).
3. National Academies of Sciences, Engineering, and Medicine, Parenting Matters: Supporting Parents of Children Ages 0-8. 2016. Washington, DC: The National Academies Press. doi: 10.17226/21868.
4. Black, M. M.; Aboud, F. E., Responsive feeding is embedded in a theoretical framework of responsive parenting. The Journal of nutrition 2011, 141 (3), 490-4.
5. Dattilo, A.M.; Carvalho, R.S.; Feferbaum, R.; Forsyth, S.; Zhao, A., Hidden realities of infant feeding: Systematic review of qualitative findings from parents. Behav Sci 2020, 10, 83; doi:10.3390/ bs10050083.
6. Harrison, M.; Brodribb, W.; Hepworth, J., A qualitative systematic review of maternal infant feeding practices in transitioning from milk feeds to family foods. Matern Child Nutr 2017, 13 (2).
7. Matvienko-Sikar, K.; Kelly, C.; Sinnott, C.; McSharry, J.; Houghton, C.; Heary, C.; Toomey, E.; Byrne, M.; Kearney, P. M., Parental experiences and perceptions of infant complementary feeding: a qualitative evidence synthesis. Obesity reviews : an offcial journal of the International Association for the Study of Obesity 2018, 19 (4), 501-517.
8. Morais, M. B.; Cardoso, A. L.; Lazarini, T.; Mosquera, E. M. B.; Mallozi, M. C.,Habits and attitudes of mothers of infants in relation to breastfeeding and artificial feeding in 11 Brazilian cities. Rev Paul Pediatr, 2017, 35(1), 39-45. doi.org/10.1590/1984-
0462/;2017;35;1;00014.
9. Bazzano, A. N.; Kaji, A.; Felker-Kantor, E.; Bazzano, L. A.; Potts, K. S., Qualitative Studies of Infant and Young Child Feeding in Lower-Income Countries: A Systematic Review and Synthesis of Dietary Patterns. Nutrients 2017, 9 (10)
10. Raman, S.; Nicholls, R.; Ritchie, J.; Razee, H.; Shafiee, S., How natural is the supernatural? Synthesis of the qualitative literature from low and middle income countries on cultural practices and traditional beliefs influencing the perinatal period.
Midwifery 2016, 39, 87-97.