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Original Paper |
Department of Nutrition, College of Human Ecology, University of Tennessee, Knoxville, Tennessee
Address reprint requests to: Srimathi Kannan, PhD, Assistant Professor, Human Nutrition Program, Department of Environmental and Industrial Health, School of Public Health, 1420, Washington Heights, University of Michigan, Ann Arbor, MI 48109-2029.
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONLIMITATIONS OF STUDYCONCLUSIONREFERENCES |
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Methods: Feeding practices (breast-feeding, formula-feeding, introduction of solid foods) were assessed at infant ages one, three, six, nine and twelve months for a total of 250 interviews conducted in the home. Mothers’ sources of information about infant feeding practices and dietary intakes of their infants were collected (24-hour recalls).
Results: Compared to their AIA counterparts, AA mothers breast-fed for significantly longer durations and introduced formula and solid foods into the infants’ diet at a later age (p<0.05). Throughout the first year, AA mothers relied primarily upon health professionals for infant feeding information compared to AIA mothers, who sought information primarily from the family network during the first six months and relied more on health professionals during the second six months of the infant’s life. Throughout the first twelve months, infants of both groups exceeded 100% of the RDA for energy, protein, calcium, iron, vitamin A, and vitamin C.
Conclusion: Health professionals, including nutrition educators, should educate AIA mothers about and encourage AA mothers to follow current feeding recommendations and guidelines about breast-feeding, formula-feeding and introducing solid foods.
Key words: infant feeding, Anglo American, Asian Indian American, breast feeding, solid foods, nutrients
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONLIMITATIONS OF STUDYCONCLUSIONREFERENCES |
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Currently, 60% of infants born in the U.S. are breast-fed [5]. This reflects a nationally representative incidence of breast feeding and varies among different ethnic groups residing in the United States. There are no data about Asian-American mothers residing in the United States regarding their breast feeding and weaning practices. Asian-American Pacific-Islander Americans include people from more than 30 different nationalities, whereas Asian-Indian American mothers belong to a single cultural sub-group. Thus, the grouping of many diverse Asian cultural groups obscures differences in infant feeding practices between cultural sub-groups [6, 7].
Hence, this research was designed to address some of the culture based differences in infant feeding practices of Asian-Indian American mothers residing in the southeastern United States and to compare these findings to a cohort group of Anglo-American mothers. Objectives of the study were to determine for both groups, the duration of breast feeding, timing of introducing formula and supplementary foods, primary and secondary sources of information about recommendations for infant feeding and dietary intake for infants aged one, three, six, nine and twelve months.
It was hypothesized that compared to Asian-Indian American mothers, Anglo-American mothers would have a higher incidence and duration of breast-feeding, would introduce solid foods later and would use professional sources of information about infant feeding. The hypothesis reflects reports in the literature about cultural differences in infant feeding practices of Anglo-American and Mexican-American mothers [8] and African-American mothers [9].
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONLIMITATIONS OF STUDYCONCLUSIONREFERENCES |
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Eligibility to participate in this study was based on the following criteria: primiparous, older than 19 years of age and middle and upper socioeconomic status, i.e., score of 
33 on the Hollingshead Four Factor Index of Social Status [10]. For the Asian-Indian American mothers, ethnicity was determined by place of birth (US or India) of the mother and national language spoken in the home (English or Hindi). They had to have lived in the United States for more than one and fewer than eight years. A residence requirement between one and eight years was chosen based on reports in the cross-cultural theoretical and empirical literature that suggest that this timeline is reflective of the acculturation process [11]. Both groups of infants had to be full term, healthy (as determined by APGAR scores) and weigh >2500 grams at birth.
Study participants received a letter describing interviews to be conducted in the home when their infants were one month of age, the group reporting of results and parents’ voluntary participation. Mothers were informed that, upon completion of the study, two infant toys would be provided as an incentive for participating. The study was approved by the institution’s committee for use of human subjects in research. Mothers gave informed consent at the one month interview.
Data Collection
The Infant Feeding Practice Questionnaire used in this study was a modified form of existing questionnaires [11]. In order to accommodate ethnic-specific information needed, both groups of mothers were asked about breast-feeding, formula-feeding, supplementary foods, vitamin/mineral supplements and mothers’ sources of information about infant feeding practices. As part of the cultural profile, language spoken in the home by the mother as well as by members of her extended family (e.g., grandmothers, maternal/paternal siblings) was asked.
When the infants were one, three, six, nine and twelve months of age, data on breast-feeding practices were collected, including number of times and length of feeding occasion over the prior 24 hours (24-hour recall method). Information about type of formula (ready to eat or concentrated liquid), brand name of formula, method of preparing formula and amount of formula a day was collected.
Supplemental foods were reported by categories: commercial baby foods, homemade foods and table food. Age of the infant when food from each of the supplementary groups was added, reasons for adding and frequency as well as amount of cereals, fruits, vegetables and meat consumed was reported by mothers. If the food was modified, food processing techniques used for this purpose were determined and recorded.
Mothers from both of the two ethnic groups indicated their primary sources of information about feeding their babies and other sources such as family (including maternal/paternal grandmother), a friend or friends and/or media. If recommendations about feeding were provided by any of these sources, mothers listed the specific recommendation or recommendations and reported the degree of their compliance. At each interview, weight, recumbent length and head circumference (DHHS, 1984) measurements of the infants were completed by the investigator (S.K.).
Detailed instruction on accurate recording of the infant’s food intake was provided to the mother at the one-month interview. Prototypes of measuring utensils (jars, bottles and cups) were also provided to enhance mother’s food recalls for her infant. The infant feeding data in this article represents 250, 24-hour recalls (125 from each ethnic group).
Data Analysis
Data were analyzed using descriptive statistics, including means and frequencies [12–14], for the number of mothers breast-feeding at one, three, six, nine and twelve months, duration of breast-feeding (in months) and the ages of the infants at introduction of formula and supplementary foods. Averages were calculated for the number of mothers using health professionals, personal network, the media or other sources of information about infant feeding at one, three, six, nine and twelve months and nutrient intake at each of these ages. Median and mode values were calculated for maternal age and APGAR scores. General Linear Model Procedure (Student’s t test) was used to compare responses by ethnic group and group differences at p<.05 were considered significant.
Published nutrient values for breast milk were inputted into the Nutritionist IV database [15]. For exclusively breast-fed infants, 750 mL/day was used in calculating calorie and nutrient intakes. For those who were exclusively formula fed, ounces/day of formula consumed was used in nutrient calculations. When infants received both formula and breast milk, the quantity of formula consumed was subtracted from 750 mL as a base amount [16–18]. For infants who received breast milk and solid foods, 750 mL/day of breast milk was used in nutrient intake calculations combined with nutrient intakes from supplementary infant foods. Databases for calculating nutrient contents of infant foods included Nutritionist IV [15] and manufacturers’ information. If an ethnic food was not listed in the data base, then Nutritive Value of Indian Foods [19] and Indian cookbooks were used as additional reference sources. Mean nutrient intakes of infants were compared to the Recommended Dietary Allowances for the appropriate age, i.e., birth to five months and six to twelve months [20].
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONLIMITATIONS OF STUDYCONCLUSIONREFERENCES |
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Incidence of Breast-Feeding at One, Three, Six, Nine and 12 Months
As shown in Table 2, there was a significant difference between groups in the incidence of breast-feeding at six, nine and twelve months. At one year after their infants’ births, none of the AIA mothers breast fed, compared to 28% of the AA mothers, who continued to breast-feed. The maximum decrease in the incidence of breast-feeding occurred between six and nine months for AA mothers, in contrast to a decrease between three and six months among AIA mothers. Reasons given by AA and AIA mothers for ceasing breast-feeding are presented in Table 3. Mothers in both groups gave reasons for ceasing to breast-feed that reflected their infants’ needs as well as their own concerns, for example, the need to return to work and associated reasons. The reasons for ceasing to breast feed cited most frequently by AA and AIA mothers, respectively, was "infant growth" and "infant appetite."
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AIA mothers introduced cereal, juice, fruits and vegetables significantly earlier than AA mothers (Table 4). During the first six months, iron-fortified rice cereal, followed by oatmeal and mixed cereals, was given most frequently by AA mothers (Table 4). AIA mothers used iron-fortified rice cereal most frequently, followed by mixed cereal, in the first six months and did not use oatmeal. Nine AIA mothers introduced rice and lentil-based food as the first supplementary foods.
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Similarly to fruits, all AIA infants were receiving vegetables by six months of age, whereas only 20 AA infants were fed vegetables at that age. The type of first vegetable fed differed between the two groups: commercial carrots for AA versus homemade salted potatoes for AIA infants.
The mean age at introduction of meat and meat substitutes was significantly different by group (7.2 versus 6.3 months for AA and AIA infants, respectively). Turkey with rice was the first meat fed to AA infants, chicken with vegetables to the AIA infants. By the mean age of 3.5 months, AIA mothers had introduced mashed or pureed cooked legumes (lentils). Lentils were not present in the diets of AA infants.
At the "weaning food ceremony" which occurred at three months of age, AIA infants were momentarily provided with an opportunity to experience flavors and textures symbolic of those of the traditional family foods (Table 5). Foods were from the five food groups: cereal (rice or wheat), legume (lentil), fruit (banana), vegetable (potato) and dairy (milk).
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Sources of Information about Infant Feeding
There was a significant difference in the sources of information used by AA and AIA mothers in the first six months of the infants’ lives. AA mothers reported that pediatricians and family members were primary and secondary sources of information, respectively (Fig. 1). In contrast, AIA mothers cited maternal/paternal grandmothers as primary advisors about infant feeding practices (Fig. 2). Both groups of mothers asked information from health professionals about positioning the baby while breast-feeding, frequency of feeds per day, preparation of formula, sequencing the introduction of solid foods and using special diets and vitamin and/or mineral supplementation. Both groups of mothers used the advice of health professionals after six months. Between six and twelve months, five AA mothers used the toll-free numbers of commercial baby food manufacturers seeking information about the sequence of introducing supplemental foods, whereas no AIA mother used this source for feeding information.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONLIMITATIONS OF STUDYCONCLUSIONREFERENCES |
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It is recommended that mothers first introduce single-grain cereals [32] and provide 24 to 30 ounces/day of formula in the diet of six-month old infants. Single-grain cereals are recommended as first foods because this provides the caregiver an opportunity to watch for onset, if any, of immediate or delayed hypersensitivity following this transitional feeding period. Both groups of mothers complied with the cereal recommendation, and AA mothers complied with the recommendation for quantity of formula a day.
AA mothers delayed the introduction of formula and solid foods as compared to AIA mothers, a practice which is consistent with those of other ethnic groups [33, 34]. Findings that AIA mothers introduced solid foods before four months are similar to those for other ethnic groups [35]. The American Academy of Pediatrics [36] and the World Health Organization [37] recommend that solid foods be introduced to infants’ diets between the ages of four and six months. The rationale for this recommendation is based on interrelated health considerations for both mother and infant [38]. For instance, weaning the infant before the age of four to six months may be associated with adverse consequences, among them exposure of the infant to environmental or food contaminants, reduced immunological protection, subsequent reduction in breast-milk production and related hormones by the mother [38].
Similarly to findings by Skinner et al. [39], both groups of mothers introduced solid foods in the following sequence: cereal, fruit, juice, vegetables and meat or meat substitutes. The sequence in which solid foods are introduced, however, is not considered important. In our study, reasons accompanying early weaning (infant sleep patterns, infant behavioral signals, hunger or weight readiness) are similar for the two groups and agree with results from other studies [2, 6, 25].
The American Academy of Pediatrics and the American Academy of Periodontics caution against feeding juices from a bottle [40]. This recommendation is supported by the finding that sugar-containing foods, including fruit beverages, that remain in contact with the baby’s teeth can promote tooth decay [40, 41]. Some mothers in this study (ten AIA and five AA) put their infants to bed with a bottle containing sweetened beverages. This undesirable feeding practice has been reported among Mexican-American mothers [26, 33, 42, 43].
In regard to cow’s milk, mothers in our study introduced cow’s milk before the recommended age of twelve months [3]. This recommendation is supported by the goal of preventing nutritionally important gastrointestinal blood loss in the infant [44, 45]. Other researchers report similar findings [24].
The role of fruits and vegetables in the infant’s diet is functional, and they are recommended as ideal first foods. Introducing fruits and vegetables in the infant diet facilitates dietary balance as well as diversification [46]. Additionally, these foods provide micronutrients (e.g., essential trace elements, including iron and zinc, and vitamin A, vitamin C and carbohydrates) [47]. Around six months, all AIA infants were receiving fruits and vegetables, commercial and/or homemade. A similar ethnic trend in the introduction of fruits and vegetables earlier than the recommended age has been reported in studies of Mexican-American [4] and African-American mothers [25].
Our findings show that AA mothers seek and use multiple sources of information about infant feeding. Similarly, Anglo-American mothers in other studies sought information from literature and the media [39]. However, AIA mothers’ sources of information in this study may reflect the maternal grandmother’s visiting period. Based on immigration regulations, a visit to the U.S. from India is usually limited to six months at one time period. Thus, whether the grandmother visits during the first or second six months of the infant’s life may have determined the primary source of information reported by AIA mothers. These cultural differences were also reported in Mexican-American mothers for whom the maternal grandmother was the primary feeding advisor [38].
Throughout the first year, AA and AIA infants received nutritionally adequate diets. Macronutrient intakes of AA infants at six and twelve months are similar to those reported by Skinner et al. [39]. Johnson et al. [48] reported higher fat intakes in African-American compared to Anglo-American infants. Similarly, significant differences between the two groups of infants in our study were in energy, fat and vitamin C intake. This finding parallels the kinds and amounts of foods fed to infants in each of the two groups. Calorically dense foods offered to AIA infants included fried vegetable-based curries and baked potato with ghee (clarified butter). It is not necessary to add salt, butter or spices to infant foods, yet most AIA mothers flavored infant foods with these ingredients.
As infant fetal hemoglobin and liver iron stores are depleted and as rapid expansion of hemoglobin and myoglobin mass and of bone progresses, the demand for a continuous supply of iron and calcium increases respectively [49]. Also, it has been suggested that iron deficiency anemia during infancy may be a risk factor for abnormal cognitive, social and motor development of infants and young children [50]. Similarly to reports by Curtis [51] and Lonnerdal [52], in our study fortified cereals, formulas and other infant foods contributed to the overall micronutrient (iron, zinc and vitamin A) adequacy in both groups of infants. In addition to breast milk, dairy products (cheese, yogurt) and fortified infant cereals provided adequate amounts of calcium throughout the first year of life.
The disparity in vitamin C intake between AA and AIA infants relates to the relatively higher quantities of juice offered to AIA infants in the first six months (an average of 6.5 ounces for AA infants versus 11.5 ounces for AIA infants). Most AA mothers offered diluted juice (n=23), compared to the same number of AIA mothers, who offered undiluted juice (n=23). Adequate intake of vitamin C rich fruit juices enhances iron absorption from non-heme iron sources, such as cereals and other plant-based foods [53]. Juice intake by infants may be a preferred practice compared to the consumption of soda pop. However, excessive fruit juice consumption can displace calorie- and nutrient-dense foods, thus potentially creating a nutrient imbalance [54] or can lead to malabsorption of sugars, especially fructose and/or sorbitol commonly found in fruit juice [55]. In 1991, the American Academy of Pediatrics Committee on Nutrition cautioned that "excessive use of fruit juice" may result in gastrointestinal problems, such as diarrhea, abdominal pain or bloating [56]. Dennison et al. [57] reported that consumption of >12 fl oz a day of fruit juice by two-year-old children was associated with short stature and obesity. Smith and Lifshitz [54] reported that excess fruit juice consumption was associated with non-organic failure to thrive in children older than one year of age. Skinner et al. [58] found no association between growth and fruit juice consumption in two-year-old children. Consistent with these findings, and with reports that fructose malabsorption is both concentration-dependent and dose-dependent [59], it is likely that AIA infants’ consumption of ten fluid ounces per day of undiluted juice may have an impact on the overall diet quality and nutritional status of the infants. AIA mothers in this study thus need nutrition advice that both recognizes the positive aspects of adequate juice intake and the potentially negative aspects of excessive juice consumption.
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LIMITATIONS OF STUDY |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONLIMITATIONS OF STUDYCONCLUSIONREFERENCES |
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CONCLUSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONLIMITATIONS OF STUDYCONCLUSIONREFERENCES |
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Feeding practices, such as cessation of breast-feeding, introduction of solid foods earlier than recommended, putting the baby to bed with a bottle containing sweetened beverages and feeding seasoned baby foods at an early age are of particular concern. Both groups of mothers should be discouraged from feeding cow’s milk before the age of one year. The challenge for health care providers, particularly nutrition educators, is to encourage compliance with recommended feeding practices by communicating to mothers potential health risks associated with these infant feeding practices while acknowledging the cultural traditions behind these practices. For Asian-Indian American mothers, the time period for infant weaning milestones, as defined by the cultural norms and constraints, appears to override current guidelines for infant feeding. Based on the personal network and sources of information, inclusion of the infant’s maternal/paternal grandmother in nutrition education sessions targeted at Asian-Indian mothers is essential.
It was encouraging to note that both groups of mothers made the transition from formula or breast milk to foods that are culturally based and offer various flavors and textures. Nutrition educators should build on this and encourage both groups of mothers to introduce consistently a wide variety of nutritionally and developmentally appropriate foods.
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REFERENCES |
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This article has been cited by other articles:
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  E. Davis-McFarland Family and Cultural Issues in a School Swallowing and Feeding Program Lang Speech Hear Serv Sch, April 1, 2008; 39(2): 199 - 213. [Abstract] [Full Text] [PDF]
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