Feeding Infants and Toddlers: A Qualitative Study to Determine Parental Education Needs

Abstract

Background:

Limited evidence-based guidance is available to parents regarding optimal child feeding practices to prevent early childhood obesity from birth to 24 months of age (B–24). The objective of this qualitative study was to determine current child feeding practices, barriers to implementation, and educational needs of parents of varying socioeconomic backgrounds as it relates to responsive feeding to prevent early obesity in children of ages B–24.

Methods:

One-on-one interviews were conducted with parents (n = 66) of children ages B–24 from both low-and non-low-income households. Interviews were audiorecorded, transcribed verbatim, and analyzed with NVivo using classical qualitative analysis.

Results:

Participants were primarily female (91%), married (53%), low-income (59%), and were not first-time parents (72%). The results revealed overarching themes, including parents' reported need for information on preparing child meals, optimal dietary intake, affordable healthy foods, promoting child self-feeding, and food and nutrition knowledge. Low-income parents more frequently requested guidance about identifying affordable healthy options and overfeeding while non-low-income parents requested information about food allergens, transitioning to solids, and creating structured mealtimes.

Conclusions:

Additional and focused outreach to parents of children ages B–24 regarding optimal feeding practices is needed especially on topics related to complementary feeding during the transition to solid food.

Introduction

In 2011, about 1 in every 10 children younger than 2 years of age in the United States had a weight-for-length percentile classified as obese,^1,2 with even higher percentages seen in low-income and underserved populations. Childhood obesity has been a growing epidemic and public health concern over the past decade due to the short- and long-term consequences.^3,4

Although children learn from their own experiences with food, external influences have a substantial impact on their food choices.^5–7 Eating behaviors in children overall are affected largely by social determinants.^5,6,8 Parents influence their children's eating behaviors through their own eating behaviors, attitudes and beliefs, and child feeding practices.^5,9 Responsive feeding is the practice of encouraging children to eat autonomously in response to their physiological needs, encouraging self-regulation and supporting cognitive, emotional, and social development.⁹ Several recent studies have found correlations between responsive feeding practices and positive impacts on dietary patterns and weight.^10–12 Recent guidelines on responsive parenting were developed for use by health professionals,⁹ but the educational needs of parents remain unknown. The objective of this qualitative study was to determine current child feeding practices, barriers to implementation, and educational needs of parents of varying socioeconomic backgrounds as it relates to responsive feeding to prevent early obesity in children of ages from birth to 24 months old (B–24).

Methods

The study methodology incorporated the links between personal beliefs and behaviors demonstrated in the Theory of Planned Behavior and the interpersonal factors and dynamic interactions of the Social Cognitive Theory.^13–15 These theories provided the theoretical models, from which the research strategy and interview questions were developed. The University of Connecticut-Storrs Institutional Review Board approval for Human Subjects was secured before recruitment and data collection.

Participants

Participants were recruited from Head Start, the Expanded Food and Nutrition Education Program, The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), health clinics, community programs, primary pediatrician offices, family practice offices, and child care centers serving families with children of ages B–24 throughout Connecticut. Inclusion criteria were as follows: parent of at least one child ages B–24, at least 18 years of age, able to speak and read English or Spanish, and typically providing at least half of the feeding for their child at the time of the study. Recruitment was conducted in person, via email, and using study flyers by research assistants, and once a parent was screened for eligibility, they were contacted to schedule an interview. Purposeful recruitment was used to oversample for parents in minority groups allowing for comparison of parents by socioeconomic status and to ensure inclusion of parents with children of differing ages B–24. Low-income was defined by a parent or family member's participation or eligibility for an income-dependent federal nutrition assistance or related program (e.g., WIC). Participants not qualifying or participating in any income-dependent food assistance or related programs were categorized as non-low-income.

Interviews

Written informed consent was conducted with each participant along with a demographic questionnaire to further confirm characteristics such as income eligibility before the interview. One-on-one interviews were conducted by a trained research assistant with each parent individually in-person at a convenient site for the participants (such as the child care or community center attended by the child, which was often the same as the recruitment site), audiorecorded with permission, and lasted about 60 minutes. The interview script was semistructured with guided prompts and included questions about feeding practices, sources of child feeding information, information received, beliefs about feeding practices, and how they make decisions about child feeding. Each interview was conducted in either English or Spanish, based on the participant's reported preference before the interview. Childcare (estimated value of $10 per hour) was provided at the interview site by a trained research assistant, to families unable to make alternative arrangements. After completion of the interview, each parent received a $20 gift card for their time.

Qualitative Analysis

The sample goal was to include 25–30 participants from each of the two defined groups (low-income and non-low-income), or once data saturation was met and no new information obtained. Sufficient numbers of participants were recruited by varying income levels to allow for future comparison of responses. Audiorecorded interviews were transcribed verbatim and transcripts were verified by the lead author involved with the interviews. The interviews were analyzed to answer the following questions from a longer script: (1) What foods or food-related practices do you think you should do but are hard to do? (2) What would you like to learn more about as it relates to feeding your child/baby? Each transcript was open-coded and analyzed for themes using the classic analysis approach with the use of a qualitative software management program, NVivo Pro 11.¹⁶ Two of the study authors served as main coders for this study. The study's lead author conducted initial exploration of the data by reviewing each transcript. Both coders read each transcript and applied codes to segments of transcript text using a basic word processing program or NVivo. Thematic analysis was then used to determine overarching themes on child feeding practices of interest among all participants, and subthemes were analyzed as stratified by socioeconomic groups.^17,18 Coders identified and defined emergent codes within the codebook. The authors grouped similar concepts into categories. Research meetings occurred between the coders until consensus was reached on major themes. Multiple reviewers were used at each stage of qualitative analysis to increase validity of the findings.¹⁹

Results

Participants

Participants (n = 66) were primarily female (91%), married (53%), employed full-time (53%), low-income (59%), and were not first-time parents (72%) (Table 1). Overall and subthemes of responses by parental income status along with sample quotes are included in Table 2.

Table 1.

Participant Demographics

Characteristic	Mean ± SD
Age (years)	31.2 ± 6.5

	n (%)
Gender
Male	6 (9.1)
Female	60 (91.9)
Race
White	43 (65.2)
Black	8 (12.1)
Other	15 (22.7)
Ethnicity
Non-Hispanic	49 (74.2)
Hispanic	17 (25.8)
Education level
Some college or higher	34 (51.5)
Less than college degree	32 (48.5)
Marital status
Single, never married	20 (31.3)
Living with partner	8 (12.5)
Married	34 (53.1)
Divorced	2 (3.1)
Number of children
1	25 (37.9)
2	28 (42.4)
3+	13 (19.7)
Age of child (months)
0–6	11 (16.7)
>6–12	22 (33.3)
>12–24	33 (50.0)
Income status
Low income	39 (59.1)
Non-low income	27 (40.9)

SD, standard deviation.

Table 2.

Thematic Results of Parent Requested Educational Topics Regarding Child Early Feeding Stratified by Income Level

Theme	Subthemes by parent income	Sample quotes
Mealtime preparation	Low-income Preparation and cooking skills	“It's not like I don't eat meat. It's just that it's expensive and I don't know how to cook it very well. So we don't […]” “I would like to know several ways to prepare vegetables so they can eat.”
Mealtime preparation	Non-low-income Baby/toddler foods	“I wish that I had known a better way to try and make your own baby food.” “Easy toddler meals or that type of thing. Just to get a little more variety in, and change things up a little bit.”
Dietary Behaviors	Low-income Increasing overall intake; identifying overfeeding	“Like find ways to get your kids to eat a little bit more.” “The quantity… what is considered a full meal, what is too much.”
Dietary Behaviors	Non-low-income Choking hazards; transition to solids	“It's really challenging introducing him to food, and I'm so afraid of choking […] I feel like I'm not as daring as I should be.” “But for solid foods, I wish there was more in terms of transitioning and what is the best time to transition.”
Affordability	Low-income Healthier options at lower cost	“I mean I do find it difficult to buy healthier food because it's expensive.”
Affordability	Non-low-income Affordable organic options	“I would love to do even more organic, it's just too costly. We don't buy organic milk, just because my husband can't stand us paying […]”
Self-feeding	Low-income Self-feed with utensils	“She plays with the silverware but she hasn't used it.”
Self-feeding	Non-low-income Self-feed without mess	“Yeah. I hate feeding her purees, because after that it was a bath time and a change of outfit.”
Food and nutrition knowledge	Low-income Healthier food variety	“Um, more healthier stuff. Like, what's healthier to feed kids.” “I guess more varieties […] Like a wider variety of options to, because that's like, it's hard to find food that a two year old can eat that's healthy, that's different.”
Food and nutrition knowledge	Non-low-income Food allergens and additives	“It would be really nice if there was better information about allergies.” “I don't know if he should just be eating healthy, healthy food. I hate […] giving him processed food, […] things that have all that additive.”

Mealtime Preparation and Cooking Skills

Parents overall reported the need for more knowledge and skills in meal preparation for their young child. This included culinary skills such as preparing and cooking age appropriate and recommended whole entrées or meals by combining foods into a complete dish.

Low-income parents were interested in learning how to cook foods that their children would be more likely to eat. They also expressed a desire to learn skills about how to prepare more meats and vegetables for their young child.

Non-low-income parents referred to mealtime preparation as an important way to avoid processed foods in the diet. One specific area of interest was learning how to make homemade baby foods, which were referred to as healthier options. Many non-low-income parents also spoke about the need for information on how to make quick and easy toddler meals, which were referred to as being different from what other family members would eat.

Dietary Behaviors

Parents across both socioeconomic groups wanted to understand more about meeting their child's dietary needs and their own role in these behaviors. Dietary intake behaviors included recommendations in dietary intake, changes in dietary patterns, and how they can improve their child's food intake.

Low-income parents expressed a concern of finding ways to get their child to increase overall food consumption. They wanted to learn strategies to get their child to eat more, finish their food, and consume more of specific food groups. Consequently, low-income parents also reported the need to identify overfeeding and to better understand how much their child should actually be eating.

Non-low-income parents spoke more about transitionary stages in their child's diet and introducing new foods and textures. They were mostly concerned about the timing and techniques used to transition from liquid to puree and eventually to solid foods. Non-low-income parents also reported that safety, such as choking hazards, was a specific area where they needed more information. This included knowledge on how to recognize and respond to signs of choking or other negative physiological responses to new foods that may harm their child.

Affordability of Food

Parents throughout the study expressed concern with maintaining a budget and still supplying optimal food choices to their children. The types of foods parents wanted to learn how to fit into their budget differed based on socioeconomic status. Affordability concerns generally focused on healthy food options, but what parents mentioned as being their preferred healthy options differed.

Low-income parents reported wanting to incorporate more healthy foods into their child's diet. Some examples provided included vegetables and high-protein food sources. When referring to healthy foods, they simply specified finding healthier versions or options in comparison to what their child was currently consuming.

Non-low-income parents also wanted to learn how to incorporate healthy foods into their child's diet. When discussing healthy foods, they spoke mostly about natural and organic options. Although not an evidence-based recommendation, non-low-income parents tended to refer to organic foods as being the healthier options to their child's current diet. Fitting organic products into their food budget was seen as a goal that parents had trouble with due to cost demands.

Self-Feeding Guidelines for Young Children

Guidelines regarding self-feeding among young children were another emerging theme that parents from both income groups desired. Parents were familiar with the concept of self-feeding, allowing their children to feed themselves, but stated that they needed to learn more about how and when to implement these types of practices. Although parents requested information on self-feeding, the aspects of self-feeding that they inquired about differed among socioeconomic groups.

Low-income parents reported needing information and direction on how to introduce different utensils for their child to use. They wanted to learn more about how to encourage their child to use spoons or other feeding tools to increase more advanced self-feeding techniques. Furthermore, they wanted to be sure that their child used the utensils properly for self-feeding as opposed to simply playing with them.

When discussing self-feeding, non-low-income parents were more concerned about how to prevent messes. They wanted to know how to encourage self-feeding without the negative outcomes they associated with messy eating. When referring to messy self-feeding, parents expressed concern for use of incorrect techniques and skills, or additional time and energy required by them after the meal.

Food and Nutrition Knowledge

The final emerging theme that parents reported on overall was food and nutrition knowledge about the foods they were feeding their young child. This included understanding what different foods were made of, not only the ingredients but also other additives as well. Parents wanted more knowledge on what nutrients were found within foods to better understand how to increase variety and provide alternative options that still meet their child's nutritional needs. In addition, parents explained that they wanted to know what else was found in foods that may contain unexpected additives, such as nonnutritive ingredients or substances.

Low-income parents were more interested in understanding which essential nutrients were found in different foods. They explained wanting to select the healthiest options and be able to substitute foods with other selections that would still provide important nutrients from what was replaced. Some low-income parents were also concerned about identifying foods that are good sources of specific nutrients, such as protein or fiber.

Non-low-income parents were mostly concerned with food additives and substances that may not be expected or found on a food label. Many parents wanted more information on potential food allergens, including food items that may commonly illicit allergic reactions or may have an unexpected additive that could cause a reaction. Non-low-income parents also wanted more information about food additives, such as food dyes, preservatives, or other flavoring substances.

Discussion

Common themes related to early child feeding were found although some specific subthemes differed by socioeconomic status of the parents. As it relates to mealtime preparation, low-income parents were more concerned about their culinary skills to prepare and cook specific foods. A previous qualitative study investigating low-income cooking practices found that parents reported less confidence in preparing recipes or meals that they wanted to cook at home.²⁰ Previous research with low income parents associated increasing vegetable intake as an important and healthy goal for their children, thus underscoring the need for improving food preparation skills.^21–23

Non-low-income parents were not as concerned about cooking skills, but were focused on the ability to prepare homemade baby foods. Although they referred to homemade baby foods as being healthier options, previous research shows no negative association with consuming commercially prepared baby foods and nutritional quality or fruit, vegetable, and micronutrient intake compared to homemade versions.^23,24 The non-low-income parents also desired the ability to prepare easy toddler meals. The specification of easy meal preparation is consistent with a previous study, which identified that primary barriers to non-low-income parents cooking at home were not related to confidence in cooking abilities, but rather an issue of convenience.²⁵ Parents, particularly higher educated and employed women, perceived home-cooked meals to take more time, be inconvenient due to schedules, and overestimated costs of preparing foods at home.

Parents also indicated interest in learning more about the role they play in affecting their child's dietary intake patterns. For low-income parents, this centered on increasing how much their child would eat. A previous qualitative study, including a smaller sample of mothers participating in WIC, identified that low-income mothers positively associated higher infant weight with child health.²⁶ While there was no comparison to non-low-income parents in this focus group study, parents expressed concern for providing enough food for their child and also acknowledged using food as a reward. Another previous study assessing parental feeding practices in diverse populations found that household income was negatively associated with pressure to eat as a controlling feeding practice.²⁷ This suggests that low-income parents may pressure their child to eat more than their non-low-income counterparts. Simultaneously, low-income parents also expressed concern in being able to identify overfeeding. This topic may have arisen from a desire to prevent their child from developing obesity. A qualitative study identifying feeding goals of low-income parents found that preventing obesity was reported as a specific goal by the majority of mothers.²² Obesity prevention was prioritized despite the disregard for goals involving feeding practices directly affecting obesity risks, including smaller portions and satiety recognition. These previous findings align with the findings within this study, where low-income parents report obesity prevention being an important topic, but still having a conflicting desire to increase children's intake. However, a focus on healthy behaviors rather than just weight is most important.

Non-low-income parents were more concerned about food intake during transitionary periods, when they should introduce their child to new foods and textures. The need for information and education on timing and techniques for transitioning to new foods may be a result of the current lack in federal dietary guidelines with corresponding feeding messages for infants and toddlers.²⁸ While the request for complementary feeding information may not have been as frequent by the low income parents in this study, other qualitative studies have indicated that low income mothers face challenges to following the guideline to delay introduction of solid foods and this was often due to family influences or motivators to cope with child reflux or sleep issues.²⁹ Furthermore, conflicting information regarding feeding was cited as a main theme from interviews and focus groups with low-income mothers as well as a need to better tailor guidance to individual mothers rather than providing general outreach.³⁰ Although there are currently global feeding recommendations set by the World Health Organization, these recommendations are also not commonly followed in other industrialized countries.^31,32

Another concern for non-low-income parents related to introducing new foods was the fear of choking. One study conducted in a non-low-income population in France also found that the majority of parents reported a fear of their child choking when introducing new food textures.³³ Even after introducing textures for the first time, fear of choking was a continuing concern for some parents.

Affordability of food was a topic of interest for parents of varying income levels. A previous qualitative study identified cost as being a commonly reported barrier to healthy feeding practices for parents of preschool-aged children.³⁴ Within this study, low-income parents were mostly concerned about affording healthier options from what they currently provided, particularly vegetables and protein sources. This focuses once again on the common concern for providing healthier food groups and the desire to incorporate more vegetables into their child's diet while maintaining a feasible budget.^20–22

For non-low-income parents, their definition of healthier food options involved mainly organic and natural foods. Despite previous research showing limited nutritional benefits to consuming organic and naturally grown foods compared to commercially grown products,^35,36 parents may still perceive these foods to be more healthful for other varieties of reasons.

Self-feeding has been identified as an important practice in the development of motor skills and abilities, as well as the increase in autonomy and self-regulation of children's intake.^9,37,38 Low-income parents were more focused on the motor skills, or their child being able to use utensils such as spoons. Spoon-feeding has been referred to as a more complex feeding skill, of which children need time to develop in sequence.³⁷ In addition, a previous study has shown that the time and age at which a healthy child develops these motor skills may vary greatly.³⁹

Non-low-income parents were more concerned about the mess associated with their children self-feeding. Previous research has shown that children who began self-feeding at earlier ages did not show any decrease in nutrient or energy intake compared to those who were fed by a caregiver, despite the difference in motor skill level.⁴⁰ The other major concern for non-low-income parents involved the negative association of time and energy with the mess related to self-feeding. Again, this may be associated with the importance of time and convenience aspects of meals for non-low-income parents.^34,41

Parents also wanted more information on food ingredients and knowledge to better identify foods that would provide optimal nutrition to their child and prevent adverse allergic or health consequences. For low-income parents, this was mainly centered around identifying which foods were more wholesome for their child and would provide them with the amounts of each nutrient they needed. A previous study in low-income parents identified several common feeding behaviors and beliefs, one of which was to introduce their children to more wholesome, nutrient-rich foods.⁴² Despite this belief, it was found that these low-income parents were still more likely to feed for nonnutritive purposes, such as providing any food possible to satisfy or calm their child. Further research is needed to better understand the driving factors related to these feeding practices.

Non-low-income parents were more concerned about food additives and allergens that are present in the foods they provide their child. Some of these concerns and confusion may be a result of recently changing recommendations on allergen-containing food introduction at younger ages and important education topics for all parents regardless of income.^43–45 In regard to other additives, a previous study found that non-low-income parents report concerns over unhealthy food additives in baby and toddler foods, including preservatives and flavorings such as sodium and sugars.⁴⁶ Content analysis studies have found that these concerns on food additives may be valid for some prepackaged baby desserts and toddler meals, but not all baby and toddler foods on the market.^47,48

Although all participants lived within the same state, there was representation from a variety of areas including urban, suburban, and rural communities. The study population also consisted primarily of mothers because only one parent, providing at least half of the child feeding, could participate. Furthermore, because income is a component of overall socioeconomic status, the differences in themes between the low-income and non-low-income parents could be attributed to other factors such as ethnicity, marital status, and education level, but this particular qualitative study was not designed to unweave those factors. Despite these limitations, this study had a socioeconomically diverse and sample within the targeted state.

Conclusion

Common themes were found among parents, suggesting effective child feeding topic materials can be developed for use in socioeconomically diverse settings. However, materials should include details that address specific learning needs identified as subthemes for each income level. For example, emphasis on strategies to prevent pressure to eat or overfeeding by low-income parents is needed while non-low-income parents may need more guidance about the current evidence related to the labeling and appropriateness of certain foods (e.g., organic) for their child. Although recently developed feeding guidelines⁹ can serve as a basis for this material development, addressing parental concerns such as step-by-step transitioning from liquid to solid diet, introducing foods with potential allergens, promoting the development of self-feeding skills, utilizing affordable healthy foods, food preparation skills, and creating balanced meals is needed. Within efforts of education and outreach to parents of young children on these topics, it is important to address and dispel misinformation by providing evidenced-based accurate information on the identified topics above and on other behaviors (e.g., screen time or sleep routines) that are associated with reduced risk of early child overweight even when the parent may not think to request it. Further material development and research are needed to provide parents from diverse socioeconomic backgrounds with child feeding guidance to help prevent early childhood obesity.

Footnotes

Acknowledgments

The authors thank the community sites that assisted us and the parents who provided time out of their schedules to be interviewed. Funding was provided by the Child Health and Development Institute of Connecticut, Inc. and the USDA Institute of Food and Agriculture Hatch Grant: Accession No. 1013855 Project No. CONS00982.

Author Disclosure Statement

No competing financial interests exist.

References

Ogden

, Carroll

, Kit

, Flegal

. Prevalence of childhood and adult obesity in the United States, 2011–2012. JAMA, 2014; 311:806.

Pan

, May

, Wethington

, et al. Incidence of obesity among young US children living in low-income families, 2008–2011. Pediatrics, 2013; 132:1006–1013.

Centers for Disease Control and Prevention (CDC). Childhood obesity facts. 2017. Available at https://cdc.gov/healthyschools/obesity/facts.htm accessed October 28, 2017.

National Institutes of Health (NIH), National Heart Lung and Blood Institute (NHLBI). Overweight and obesity-NHLBI, NIH. National Institutes of Health. 2017. Available at https://nhlbi.nih.gov/health/health-topics/topics/obe/ accessed November 27, 2017.

Hoffmann

, Marx

, Kiefner-Burmeister

, Musher-Eizenman

. Influence of maternal feeding goals and practices on children's eating behaviors. Appetite, 2016; 107:21–27.

Kiefner-Burmeister

, Hoffmann

, Meers

, et al. Food consumption by young children: A function of parental feeding goals and practices. Appetite, 2014; 74:6–11.

Patrick

, Nicklas

. A review of family and social determinants of children's eating patterns and diet quality. J Am Coll Nutr, 2005; 24:83–92.

Wang

, Wu

, Wilson

, et al. Childhood obesity prevention programs: Comparative effectiveness review and meta-analysis. Comp Eff Rev No 115 (Prepared by Johns Hopkins Univ Evidence-based Pract Center). 2013; No. 13-EHC081-EF. Available at https://ncbi.nlm.nih.gov/pubmedhealth/PMH0057326/ accessed December 10, 2017.

Pérez-Escamilla

, Segura-Pérez

, Lott

, on behalf of the RWJF HER Expert Panel on Best Practices for Promoting Healthy Nutrition, Feeding Patterns, and Weight Status for Infants and Todders from Birth to 24 Months. Feeding guidelines for infants and young toddlers: A responsive parenting approach. Durham, NC: Healthy Eating Research, 2017. Available at http://healthyeatingresearch.org

10.

Daniels

, Mallan

, Nicholson

, et al. An early feeding practices intervention for obesity prevention. Pediatrics, 2015; 136:e40–e49.

11.

Hohman

, Paul

, Birch

, Savage

. INSIGHT responsive parenting intervention is associated with healthier patterns of dietary exposures in infants. Obesity (Silver Spring), 2017; 25:185–191.

12.

Savage

, Birch

, Marini

, et al. Effect of the INSIGHT responsive parenting intervention on rapid infant weight gain and overweight status at age 1 year: A randomized clinical trial. JAMA Pediatr, 2016; 170:742–749.

13.

Ajzen

. The theory of planned behavior. Organ Behav Hum Decis Process, 1991; 50:179–211.

14.

Godin

, Kok

. The theory of planned behavior: A review of its applications to health-related behaviors. Am J Heal Promot, 1996; 11:87–98.

15.

Bandura

. Health promotion from the perspective of social cognitive theory. Psychol Health, 1998; 13:623–649.

16.

Thomas

. A general inductive approach for analyzing qualitative evaluation data. Am J Eval, 2006; 27:237–246.

17.

Braun

, Clarke

. Using thematic analysis in psychology. Qual Res Psychol, 2006; 3:77–101.

18.

Tuckett

. Applying thematic analysis theory to practice: A researcher's experience. Contemp Nurse, 2005; 19:75–87.

19.

Patton

. Enhancing the quality and credibility of qualitative analysis. Health Serv Res, 1999; 34(5 Pt 2):1189–1208.

20.

Engler-Stringer

. The domestic foodscapes of young low-income women in Montreal: Cooking practices in the context of an increasingly processed food supply. Health Educ Behav, 2010; 37:211–226.

21.

Hingle

, Beltran

, O'Connor

, et al. A model of goal directed vegetable parenting practices. Appetite, 2012; 58:444–449.

22.

Goulding

, Lumeng

, Rosenblum

, et al. Maternal feeding goals described by low-income mothers. J Nutr Educ Behav, 2015; 47:331–337.e1.

23.

Beinert

, Hernes

, Haugen

, Øverby

. No long-term effect of a 2-days intervention on how to prepare homemade food, on toddlers' skepticism for new food and intake of fruits and vegetables and sweet beverages: A randomized, controlled trial. BMC Res Notes, 2017; 10:607.

24.

Reidy

, Bailey

, Deming

, et al. Food consumption patterns and micronutrient density of complementary foods consumed by infants fed commercially prepared baby foods. Nutr Today, 2018; 53:1.

25.

Robson

, Crosby

, Stark

. Eating dinner away from home: Perspectives of middle-to high-income parents. Appetite, 2016; 96:147–153.

26.

Baughcum

, Burklow

, Deeks

, et al. Maternal feeding practices and childhood obesity: A focus group study of low-income mothers. Arch Pediatr Adolesc Med, 1998; 152:1010–1014.

27.

Wehrly

, Bonilla

, Perez

, Liew

. Controlling parental feeding practices and child body composition in ethnically and economically diverse preschool children. Appetite, 2014; 73:163–171.

28.

Raiten

, Raghavan

, Porter

, et al. Executive summary: Evaluating the evidence base to support the inclusion of infants and children from birth to 24 mo of age in the dietary guidelines for Americans—“the B-24 Project.”. Am J Clin Nutr, 2014; 99:663S–691S.

29.

Horodynski

, Olson

, Arndt

, et al. Low-income mothers' decisions regarding when and why to introduce solid foods to their infants: Influencing factors. J Community Health Nurs, 2007; 24:101–118.

30.

Savage

, Neshteruk

, Balantekin

, Birch

. Low-income women's feeding practices and perceptions of dietary guidance: A qualitative study. Matern Child Health J, 2016; 20:2510–2517.

31.

Foote

, Marriott

. Weaning of infants. Arch Dis Child, 2003; 88:488–492.

32.

World Health Organization (WHO). Complementary feeding. WHO. 2018. Available at http://who.int/nutrition/topics/complementary_feeding/en/ accessed October 2, 2018.

33.

Marduel Boulanger

, Vernet

. Introduction of new food textures during complementary feeding: Observations in France. Arch Pédiatr, 2018; 25:6–12.

34.

Martin-Biggers

, Spaccarotella

, Hongu

, et al. Translating it into real life: A qualitative study of the cognitions, barriers and supports for key obesogenic behaviors of parents of preschoolers. BMC Public Health, 2015; 15:189.

35.

Magkos

, Arvaniti

, Zampelas

. Organic food: Nutritious food or food for thought? A review of the evidence. Int J Food Sci Nutr, 2003; 54:357–371.

36.

Bourn

, Prescott

. A comparison of the nutritional value, sensory qualities, and food safety of organically and conventionally produced foods. Crit Rev Food Sci Nutr, 2002; 42:1–34.

37.

van den Engel-Hoek

, van Hulst

KCM

, van Gerven

MHJC

, et al. Development of oral motor behavior related to the skill assisted spoon feeding. Infant Behav Dev, 2014; 37:187–191.

38.

Dwyer

, Butte

, Deming

, et al. Feeding infants and toddlers study 2008: Progress, continuing concerns, and implications. J Am Diet Assoc, 2010; 110:S60–S67.

39.

Carruth

, Skinner

. Feeding behaviors and other motor development in healthy children (2–24 months). J Am Coll Nutr, 2002; 21:88–96.

40.

Carruth

, Ziegler

, Gordon

, Hendricks

. Developmental milestones and self-feeding behaviors in infants and toddlers. J Am Diet Assoc, 2004; 104:51–56.

41.

Bava

, Jaeger

, Park

. Constraints upon food provisioning practices in “busy” women's lives: Trade-offs which demand convenience. Appetite, 2008; 50:486–498.

42.

Russell

, Taki

, Azadi

, et al. A qualitative study of the infant feeding beliefs and behaviours of mothers with low educational attainment. BMC Pediatr, 2016; 16:69.

43.

Meyer

. Infant feeding in the first year. 2: Feeding practices from 6–12 months of life. J Fam Health Care, 2009; 19:47–50.

44.

Togias

, Cooper

, Acebal

, et al. Addendum guidelines for the prevention of peanut allergy in the United States: Report of the National Institute of Allergy and Infectious Diseases–sponsored expert panel. J Allergy Clin Immunol, 2017; 139:29–44.

45.

Turner

, Campbell

. Implementing primary prevention for peanut allergy at a population level. JAMA, 2017; 317:1111.

46.

John

, Cogswell

, Zhao

, et al. US consumer attitudes toward sodium in baby and toddler foods. Appetite, 2016; 103:171–175.

47.

Cogswell

, Gunn

, Yuan

, et al. Sodium and sugar in complementary infant and toddler foods sold in the United States. Pediatrics, 2015; 135:416–423.

48.

Elliott

, Conlon

. Packaged baby and toddler foods: Questions of sugar and sodium. Pediatr Obes, 2015; 10:149–155.