Comparison of Feeding Practices in Infants in the WIC Supplemental Nutrition Program Who Were Enrolled in Child Care as Opposed to Those with Parent Care Only

Abstract

Background:

The environment or setting to which an infant is exposed is crucial to establishing healthy eating habits and to preventing obesity. This study aimed to compare infant feeding practices and complementary food type between parent care (PC) and childcare (CC) settings among infants receiving the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

Materials and Methods:

This study sampled 105 dyads of mothers and infants between 2 to 8 months of age from a WIC office in Central Illinois. Mothers completed a cross-sectional survey to assess their infant feeding practices and demographic characteristics. CC was defined as infants receiving 10 hours or more per week of care from a nonparental caregiver.

Results:

Almost half of the infants (44%) were enrolled in CC. Infants in CC had an average of 29 hours of care per week compared with 0.64 hours in the PC group (p<0.01). There were no differences between the two groups in age, sex, race/ethnicity, preterm birth, and birth weight. Overall, there were no significant differences in breastfeeding initiation and duration. The average age at formula introduction was earlier for PC infants (0.90±1.16 months) than for CC infants (1.66±1.64 months) (p=0.03). PC infants stopped breastfeeding at 1.96±1.15 months compared with 2.31±1.64 months for CC infants (p=0.080). Among complementary foods introduced to infants, the primary food type was infant cereal, followed by baby food of fruits and vegetables, 100% fruit juice, and meat-based baby food. The timing of introduction and the types of complementary foods were similar between study groups.

Conclusions:

CC use is not a significant influence on breastfeeding rates, introduction of complementary foods, and types of complementary foods; however, it does influence when formula is introduced. The findings support the need for infant nutrition education and breastfeeding promotion targeting WIC mothers, regardless of their pattern of CC.

Introduction

Infant feeding practices are important contributors to obesity risk.^1–3 The timing of the introduction of formula feeding, as well as complementary foods, is a critical part of an infant's development, feeding patterns, and weight status. The American Academy of Pediatrics (AAP) Section on Breastfeeding^4–6 recommends that infants be breastfed exclusively for 6 months following birth, supplemented by the introduction of complementary foods after 6 months of age. Grummer-Strawn et al.⁷ found that infants who start eating complementary foods prior to 4 months of age are more likely to discontinue breastfeeding by 6 months and to consume fatty, sugary food and sweetened drinks by 1 year of age. However, several research studies have suggested that one-third of American infants consume complementary foods earlier than 6 months of age.^4,8

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package was recently revised in accordance with the 2005 Dietary Guidelines for Americans and infant feeding recommendations by the AAP to encourage and support longer breastfeeding, to delay the introduction of complementary foods, and to offer a more diverse variety of foods.⁹ WIC is a federal program administered by the U.S. Department of Agriculture Food and Nutrition Service. This program allocates a specific amount of grant money to State WIC agencies to provide supplemental foods, healthcare referrals, and nutrition education for low-income pregnant, breastfeeding, and nonbreastfeeding postpartum women and to infants and children up to 5 years of age who are found to be at nutritional risk.⁹ Previous studies showed that WIC participants are less prone to breastfeed, with or without formula supplementation, compared with non-WIC participants.^10–14 Since this revision in the WIC food package, there has been a significant increase in the number of WIC mothers who receive the full breastfeeding package, which provides the largest quantity of supplemental foods to meet the needs of the breastfeeding mother.^15–17 There is limited information about infant food consumption pattern since the WIC food package was revised.

Currently in the United States there are many dual-career households, and a majority of infants who are raised in these households spend a large amount of time in childcare (CC) settings outside of their homes.¹⁸ CC providers can influence dietary intake and the promotion of a healthy diet for infants.^19–21 Kim and Peterson²² reported that infants in non–parental care (non-PC) settings were less likely to meet the recommended infant feeding practices. In particular, CC by relatives is associated with lower breastfeeding initiation rates and higher rates of the early introduction of solid foods.²² Among the WIC population, children in relative care have a greater risk of short breastfeeding duration compared with PC users.²³ Non-WIC participants using relative care or center-based care also have a greater risk for short breastfeeding duration compared with PC users.²³ The transitions of infants from liquid to solid foods has not been fully investigated, specifically concerning the introduction and type of complementary foods consumed by infants in CC and PC.

The objective of this study was to assess infant feeding practices specifically in breastfeeding, formula feeding, and the time of introduction and type of complementary foods consumed by infants in CC and PC among WIC participants in an office in the Central Illinois. Our hypothesis was that a decrease in the duration of breastfeeding, as well as the early introduction of fruit juice and complementary solid foods, is more prevalent in CC compared with PC infants.

Materials and Methods

Participants and recruitment

This study used a baseline survey of the Caretaker Research Advancing Youth Obesity and kNowledge (CRAYON) study to assess infant feeding practices among WIC participants. Mothers and infants were recruited by trained CRAYON research assistants in the waiting room at a Central Illinois WIC office. Our inclusion criteria were that infants be within the ages of 3–7 months, targeting the weaning age to document the first introductory solid foods, and must be enrolled in the WIC program. Because of mothers' and primary caregivers' misreporting the infant age, we have included 2 and 8 months of age in the study sample (n=3). We calculated the age in months based on the measurement date and birth date extracted from the WIC database. A sample of 107 mother–infant dyads completed our study from October 2009 to August 2011, with an initial response rate of 278 pairs. At the end of the study, two infants were excluded because they were not enrolled in WIC but had visited the Public Health Department for other reasons. The WIC program enrollment status was verified from the WIC database. The final sample of infants was 105, with a range in age from 2 to 8 months (average age, 4.1 months; standard deviation, 1.7 months).

Upon recruitment, the biological mother or primary caregiver provided informed consent and personal contact information. Recruitment was concurrent with the new WIC food package, which was enacted in October 2009 in the study WIC office. The mothers who completed a study questionnaire were given a gift certificate upon completion. All of the study procedures were approved by the University of Illinois Institutional Review Board with full review.

Measures

The following information was collected by the survey questionnaire: gender, race/ethnicity, infant birth date, infant birth weight, duration of pregnancy, maternal weight status at pre- and postpregnancy, maternal marital status, employment status, the age CC began, and the number of hours of CC use. CC was defined as infants receiving 10 hours or more per week of care from a non–parental caregiver. CC providers were defined as any non–parental caregivers such as relatives, home-based caregivers, and center-based caregivers. Complementary food was defined as any cereal or baby food in jars or prepared foods.

Feeding practices of the infant were assessed by the survey questions about the age at introduction of formula, solid foods, types and quantity of food offered, the types of beverage choices offered, frequency of feedings, and practices on the introduction of solid foods for infants. The infant feeding practices questions were used and modified from the Feeding Infants and Toddlers (FITS) survey.⁴ Breastfeeding practices used the survey questions of “How old was your child when you stopped breastfeeding?” and “Was your child ever breast-fed?” Ever breastfeeding and current and exclusive breastfeeding rates were based on dichotomous Yes/No questions from the survey. Age of complementary food introduction was obtained with a response of “never” or completing the age (months). Data were excluded from any analysis comparing food types between PC and CC if the infant had not yet been introduced to complementary foods. Other feeding practices questions were created into a dichotomous Yes/No variable from a survey question that asked for the age of introduction of cereal, baby food, and cow's milk. Formula introduction was based on a survey question asking the age they began feeding formula, with options for a response including “never” or completing the age (months).

Data analysis

A descriptive analysis was done to determine the characteristics of the infants and biological mothers or primary caregivers (98% of biological mothers) by CC use (Table 1). A bivariate analysis was done on CC use and infant feeding practices, including types of complementary foods consumed in the diet. To analyze the food type of complementary foods, we used the subsample of infants who had already started complementary foods (n=49). Descriptive statistics (mean, standard deviation, frequencies, and percentage) were conducted for samples between the CC and PC groups. For continuous variables, a two-way independent t test between CC and PC groups was used. For categorical variables, the chi-squared test with the null hypothesis that the particular variable was distributed similarly between CC and PC was used. All the analyses were performed using SAS version 9.1 software (SAS Institute Inc., Cary, NC). Statistical significance was set at p≤0.05.

Table 1.

Sociodemographic Characteristics of Women, Infants, and Children Program Infants

	Total subjects (n=105)	Parent care (n=59)	Child care (n=46)	p value
Child characteristic	2.41±1.4	2.0±1.1	2.48±1.4	0.45
Age at childcare introduction (months)
Child care (hours/week)	13.1±15.9	0.64±2.0	29±11.0	<0.01
Age (months) at recruitment	4.10±1.7	3.9±1.5	4.3±1.9	0.24
Birth weight (kg)	3.31±0.5	3.3±0.5	3.3±0.58	0.65
Preterm (<37 weeks of gestation)	13 (12.4)	8 (13.8)	5 (10.9)	0.97
Boys	38 (36.2)	21 (35.6)	17 (36.9)	0.89
Race/ethnicity
Hispanic/Latino	8 (7.6)	5 (8.5)	3 (6.5)	0.71
Black/African American	30 (28.6)	15 (25.4)	15 (32.6)
Asian	8 (7.6)	5 (8.5)	3 (6.5)
White	46 (43.8)	27 (45.8)	19 (41.3)
Mixed/Native	21 (20.0)	12 (20.3)	9 (19.6)
Maternal characteristic
Education (years of education)	13±2.6	12.9±2.6	13.2±2.5	0.59
Age (years)	26.0±5.4	26.4±5.7	25.5±5.0	0.53
Married	46 (43.8)	28 (47.5)	18 (39.1)	0.39
Single parent home	41 (39.1)	18 (30.5)	23 (50)	0.04
U.S. born	92 (87.6)	50 (84.8)	42 (91.3)	0.31
Body mass index (kg/m²)
Prepregnancy	31.7±20.7	31.7±22.3	31.7±18.3	0.99
Postpregnancy	32.6±19.5	32.3±20.6	32.9±18.1	0.86
Maternal employment (employed or student)	47 (44.8)	13 (22.0)	34 (73.9)	<0.01

Data are mean±standard deviation values or number (%), as indicated.

Results

Demographic characteristics of the study sample are presented in Table 1. The average age of mothers was similar between the two groups: 26.4±5.7 years for the PC group and 25.5±5.0 for the CC group. The two groups of mothers/caregivers had similar educational backgrounds (12.9±2.6 years for the PC group and 13.2±2.5 years for the CC group). In addition, 47.5% of PC mothers/caregivers were married compared with 39.1% of CC mothers/primary caregivers; however, this was not statistically significant. The percentage of single mothers (i.e., mothers living alone without a significant other) was significantly greater in the CC group at 50%, compared with 30.5% for the PC mothers. Fewer than half of the study mothers/caregivers were employed, but maternal employment was significantly higher in the CC group at 73.9% versus 22.0% in the PC group. The average age of infants was not significantly different between the two groups (3.9±1.5 months in the PC group and 4.3±1.9 months in the CC group). A majority of the study infants were born full term and had U.S.-born parents. There were no major differences between the two study infant groups in race and ethnicity; of the total study infants, 43.8% were white, 28.6% African American, 7.6% Hispanic/Latino, 7.6% Asian, and 20% mixed race.

Infant feeding practices by CC type are summarized in Table 2. The only significant finding was the average age at formula introduction, which was significantly earlier for the PC group (0.90 months) than for the CC group (2.31 months). Although the difference was not statistically significant, PC infants also had a numerically earlier average age for stopping breastfeeding compared with CC infants. The average age of introducing complementary foods did not differ significantly between the PC group and the CC group. A slightly higher rate of infants who had ever breastfed was noted for the CC group compared with the PC group, whereas the current breastfeeding rate was reversed.

Table 2.

Infant Feeding Practices by Childcare Use Among Women, Infants, and Children Program Infants

	Parent care (n=59)			Child care (n=46)
	n	Mean or %	SD	n	Mean or %	SD	p value difference by child care
Prevalence or average in months breastfeeding
Ever breastfed	44	73.3		38	82.6		0.258
Currently breastfed	22	36.7		14	30.4		0.502
Currently exclusive breastfeeding	9	15.0		6	13.0		0.775
Stopped breastfeeding (months)	21	1.96	1.15	24	2.31	1.64	0.080
Introduction of formula (months)	48	0.90	1.16	37	1.66	1.64	0.030
Introduction of complementary foods (months)	25	4.28	1.03	24	4.51	0.96	0.292
Introduced soy milk	5	8.4		3	6.8		0.712
Currently complementary foods	25	42.4		24	52.2		0.540

The percentage difference between child care and parent care was tested by chi-squared test.

Table 3 provides the types of complementary foods consumed by infants in the PC and CC groups, which were not statistically different by CC use. The universally consumed food was infant cereals (100% for both groups), followed in frequency by baby food of fruits and vegetables, infant cereal from a bottle, 100% fruit juice, meat-based baby food, and chopped fruits and vegetables. There was much less frequent consumption of other types of complementary foods. Of those, grains (bread or crackers) were consumed in similar frequencies by PC and CC infants, but five times as many CC infants (20.8%) consumed chopped/mashed meats as PC children (4.0%), and over twice as many CC infants (16.7%) were fed grains (noninfant cereal, pasta, rice, and muffins) as PC infants (8.0%). In contrast, almost twice as many PC infants (8.0%) were given fruit cocktail, fruit-flavored drinks, or less than 100% fruit juice as CC infants (4.2%).

Table 3.

Complementary Food Type by Childcare Use Among Women, Infants, and Children Infants

	Parent care (n=25)		Child care (n=24)
	n	%	n	%	p value difference by child care
Food items
Infant cereal	25	100	24	100
Infant cereal from a bottle	17	68.0	13	54.2	0.576
Grains (bread or crackers)	5	20.0	6	25.0	0.504
Grains (noninfant cereal, pasta, rice, muffin)	2	8.0	4	16.7	0.373
Baby food (pureed or in jar)
Fruits/vegetables	21	84.0	21	87.5	0.389
Meats	8	32.0	9	37.5	0.498
Chopped/mashed
Fruits/vegetables	7	28.0	10	41.7	0.281
Meats	1	4.0	5	20.8	0.075
100% fruit juice (from bottle or cup)	9	36.0	9	37.5	0.724
Fruit cocktail, fruit-flavored drink, or less than 100% fruit juice	2	8.0	1	4.2	0.246

Calculations are shown for infants who had started complementary foods. The percentage difference between child care and parent care was tested by chi-squared test.

Discussion

The goal of this study was to examine the practices of breastfeeding, formula feeding, and introduction and type of complementary foods between CC and PC WIC infants, a low-income population. We expected that infants in the CC group would have had a decreased duration of breastfeeding and earlier introduction of complementary foods, considering the large percentage of single mothers using CC and findings from previous research.^22–25 However, there were no significant differences in duration of breastfeeding or in the introduction and type of complementary feeding by CC use. The only observed difference between the groups was age at introduction of formula feeding, with PC infants starting about 0.5 month earlier than CC infants (p=0.03). The infants in the CC group showed a trend toward consuming a greater variety of complementary food than infants in PC group. There were no significant differences in age, sex, race/ethnicity, preterm delivery, and birthweight between the two study groups, suggesting the findings are not biased by infants' characteristics.

There is limited information available to compare feeding practices between CC and PC WIC infants. Shim et al.²³ reported WIC participation and CC use to be independently associated with short breastfeeding duration. The results of this study do not support the potential negative effect of CC on infant feeding practices. Regardless of CC use, both the PC and CC groups did not meet the AAP infant feeding recommendations. Because the study WIC office had fully implemented the new WIC food package at the time of our study, we expected that study infants would improve or adhere to the AAP infant feeding recommendations. However, our findings did not meet the expectations. The observed short breastfeeding duration, early formula introduction, and early introduction of complementary foods in our sample of WIC infants were similar or worse than those of the previous WIC research.^{10–15,26–28}

The FITS study provides food and nutrient intake data using a nationally representative sample of infants and toddlers, including WIC infants 4–6 months of age.¹¹ We compared our results with those for nationally representative WIC infants in the FITS study. The average breastfeeding duration in our study is 2 months shorter than the average breastfeeding duration of WIC infants surveyed by the FITS study. When looking at the list of complementary food types in Table 3, CC infants are offered a larger breadth of foods compared with PC infants. The greater variability of foods may be a reflection of the foods served in the various CC settings. Our study found a lower percentage of infants was fed complementary juices and formula than the WIC infants from the FITS study. This finding may be related to the wider age range included in our study sample; our study sampled 2–8 month olds, whereas FITS sampled only 4–6 month olds.

Although our study found no improvements of infant feeding practices, there is a need for better understanding of the barriers and facilitators contributing to infant feeding practices of WIC mothers. Studies have raised the importance of mothers' family and social environments in their infant feeding decisions and practices.^3,6,29,30 The U.S. Preventative Services Task Force concluded that the most successful interventions included Baby Friendly Hospitals, worksite lactation programs, and peer support, whereas formal educational services (especially on an individual level) did not significantly affect rates but were more successful than “usual care.”²⁹ A systematic review of WIC-related breastfeeding research reported that barriers include lack of support inside and outside the hospital, return to work, and sociocultural barriers.³¹ WIC care providers need to understand the complex sociocultural factors and healthcare system-related barriers that may impact mothers' infant feeding decisions and practices.^32,33 At an interpersonal level of influence, WIC mothers consider sociocultural dimensions such as peer pressure, family, tradition, and culture to impact their infant feeding decisions the most.^34,35 Thus, it is imperative to understand and incorporate motivational factors for low-income mothers to meet the recommendations in the context of public health and the healthcare system.

Our study has some limitations related to social desirability reporting bias, CC definition, study design, and sample size. First, we used a CC definition based on the number of hours, which may have not been ideal. A definition based on the types of CC settings, such as formal centers or informal settings, may have shown differences in feeding practices as demonstrated in previous studies.^23,25 In addition, we did not control for differences in CC settings, such as center-based, relative and nonrelative care, and their compliance with the AAP infant feeding recommendations, which may have accounted for the lack of differences seen in this study.

The types of complementary foods offered to the infants might have varied among the different CC settings. Furthermore, follow-up studies are necessary to understand the effects of feeding practices and the transition to solid and table food consumption between infants in informal care, formal care, and PC. We used a cross-sectional study design and a questionnaire not validated prior to study, limiting our ability to investigate causal relationships. We targeted the weaning period of infant age (4–6 months) to minimize the recall bias on CC use and infant feeding practices, and the questionnaire asked only about current infant feeding practices, rather than retrospective questions that rely on the accuracy of participants' recall. In addition, study results are not generalizable to all U.S. WIC infants. Finally, our low sample size might have prevented us from detecting differences between CC and PC and made it difficult to capture the potential variety of complementary food types.

In conclusion, this study suggests that CC use may not influence infant feeding practices among WIC mothers. Further exploration of the underlying sociocultural factors that determine CC use and infant feeding decisions among WIC mothers is warranted. In addition, the revised WIC food package program, including nutrition education, may not adequately serve the needs of low-income mothers. Additional research is necessary to strengthen the existing WIC program by providing more culturally competent motivational strategies to help mothers delay the introduction of formula and complementary foods, as well as more comprehensive education focused on the transition from liquid to solid foods.

Footnotes

Acknowledgments

We would like to thank the Urbana-Champaign Public Health District's WIC program staff for their cooperation with this research. Without their help, this research would not have been made possible. We would also like to acknowledge the CRAYON students, Justine Britten, Hannah Noonan, Mary Kate Van Dyne, Dennise Staab, Tiffany Freeman, Mary Hayman, and Professor Jae Eun Shim at Dae Jeon University for their unwavering assistance in this study. Lastly, we greatly appreciate Ms. Joyce Newman and Lindsay M. Cortright at East Carolina University for their great suggestions on this manuscript. This work was in part supported by grant NRF-2011-330-B00190 from the National Research Foundation of Korea funded by the Korean Government, an internal grant at the University of Illinois, and a grant from the Illinois Council on Food and Agricultural Research.

Disclosure Statement

No competing financial interests exist.

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