Sharon M.

Karp, PhD, RN, CPNP, and Melanie Lutenbacher, PhD, APRN, FAAN

Infant Feeding
Practices of
Young Mothers
among some ethnic groups (Ogden et al.,
ABSTRACT 2010). All of these dire statistics mean that
Purpose: To specifically examine infant feeding practices in a sample of health problems such as hypertension, type
young mothers. 2 diabetes mellitus, asthma, dyslipidemias,
Study Design and Methods: A cross-sectional, descriptive/exploratory design and sleep disorders (all known to be linked
with author-developed measures was used to assess maternal demograph- to being overweight) are on the rise. Evi-
ics, and knowledge of and practices related to infant (6–12 months of age) dence is growing that even preschoolers
and school-aged children are developing
feeding.
complications from being overweight, in-
Results: Numerous inappropriate feeding practices were identified in this
cluding metabolic conditions and risk fac-
sample of predominately low-income, African American young mothers (n = tors for later cardiac disease (Cali, &
67). More than half (52%) of the mothers had a BMI ≥ 25, with 27% having Caprio, 2008; Williams, Strobino, Bollella,
a BMI ≥ 30. Most mothers attempted to breastfeed (53%), but only 25% & Brotanek, 2004).
breastfed beyond 6 months. Inappropriate food choices for infants (such as The foods that mothers feed their chil-
french fries), practices such as putting cereal in their babies’ bottles (82%), dren, coupled with how they feed them,
and starting solid foods before 6 months of age (64%) were reported. In this develop the foundation for food consump-
study, a shift from a balanced diet including adequate fruits and vegetables tion throughout life (Savage, Fisher, &
toward less nutrient-dense foods occurred when infants were approximately Birch, 2007). Mothers decide if they will
7 to 9 months of age. breastfeed, when to initiate solid foods,
and the amount and type of solid foods,
Clinical Implications: Most mothers in this study were overweight them-
juices, and other nonmilk substances they
selves, and had initiated less than optimal feeding practices in their young
will give their infants. Although breast-
children. Given the identified relationship between a mother’s diet and her feeding is frequently noted to be protec-
infant’s diet over time, it is clear that nurses should consider developing tive against the development of obesity
interventions to both promote early healthy infant feeding practices and (Bergmann et al., 2003; Gillman, 2002;
assist young mothers to improve their nutrition simultaneously. Nurses can Owen, Martin, Whincup, Smith, & Cook,
also target grandmothers and other family members who provide infant care 2005), only 77% of all women actually
in attempting to improve family nutrition. initiate breastfeeding, and 40% continue
Key Words: Complementary feeding; Feeding methods; Infant nutrition; to breastfeed for at least 6 months (Mc-
Young mothers. Dowell, Wang, & Kennedy-Stephenson,
2008). The percentage for young mothers
is even lower with only 43% of mothers

R
apid weight gain during infancy increases the
risk of child and adult obesity (Ong, Emmett,
Noble, Ness, & Dunger, 2006; Stettler, Ku-
manyika, Katz, Zemel, & Stallings, 2003). In
the last 3 decades the prevalence of obesity
among American children has doubled and even tripled
across some groups (Ogden, Carroll, Curtin, Lamb, &
Flegal, 2010; Ong et al., 2006). Almost one quarter of
children 2 to 5 years of age are now at or above the 85th
percentile on the BMI chart, with higher percentages
98 volume 36 | number 2
under the age of 20 years initiating breastfeeding (Mc-
Dowell et al., 2008). Ong et al. (2006) have suggested
that dietary intake at the age of 4 months may be predic-
tive of the risk for childhood obesity, and findings from
prior studies suggest that mothers routinely tend to over-
feed their infants and have difficulty providing a balanced
amount of calories and nutrients (Devaney, Ziegler, Pac,
Karwe, & Barr, 2004; Skinner, Ziegler, Pac, & Devaney,
2004). One of the foods that has been implicated in
consumption of excessive calories in infants is juice, a
March/April 2011

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Inappropriate infant feeding practices can predispose
children to poor eating habits, obesity, and health
problems throughout their life.
commonly fed food item during infancy (Bonuck & Kahn,
2002; O’Connor, Yang, & Nicklas, 2006). Typically, in-
fants are fed a variety of fruits and vegetables, but prior
studies have concluded that the quality and quantity of
fruits and vegetables decrease quickly in the last part of
the first year of life (Fox, Pac, Devaney, & Jankowski,
2004). Reasons for this remain unclear.
As a group, younger women with low educational and
low socioeconomic status have been shown to breastfeed
less often, initiate solid foods sooner, and provide less
nutritious foods to their children than a similar group of
older mothers (Dennis, 2002; Fein, Labiner-Wolfe, Scan-
lon, & Grummer-Strawn, 2008; Spear, 2006). Younger
mothers also have less knowledge of nutrition and infant
developmental milestones related to eating and tend to
rely on their own mothers for information about feeding
their children (Black, Siegel, Abel, & Bentley, 2001). In
many studies about infant feeding, young mothers are
compared with older mothers (Dennis, 2002; Fein et al.,
2008; Spear, 2006), and this has made it difficult to dis-
cern whether the differences found between the maternal
age groups are related to their age or development, or
March/April 2011
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
might be a function of their educational
level and socioeconomic status (Fein et
al., 2008; Spear, 2006). This study was
designed, therefore, to specifically ex-
amine the infant feeding practices in a
sample of young mothers, not compar-
ing them with other, older mothers, and
was important to do in order to discover specific inap-
propriate feeding practices among young mothers that
might be most amenable to targeted interventions. With
the increasing linkages between early feeding and later
obesity, gaining more understanding about these practices
in order to promote healthy feeding for this high-risk group
of mothers and infants is critical.
Study Design and Methods
A descriptive/exploratory design was used, and an author-
developed measure assessed maternal demographics, and
knowledge of and practices related to infant feeding. The
study was conducted in a large metropolitan area in the
Southeastern United States. After receiving Institutional
Review Board approvals, a convenience sample of 70
first-time young mothers were approached and recruited
from a primary care pediatric clinic and a Women, Infant,
and Children (WIC) clinic in the area. All interviews were
conducted in person by the first author. To be included in
the study, participants had to be (1) a first-time mother
between 15 and 22 years of age, with an infant between
the ages of 6 and 12 months (gestational age at birth
MCN 99
≥30 weeks); (2) willing and able to provide informed income, and level of education. Maternal BMI was calcu-
consent or assent; and (3) able to read, comprehend, and
lated from these data by dividing weight in kilograms by
speak English. Young women up to the age of 22 years height in meters squared, following the guidelines of the
were included to be able to capture those who were 21National Institutes of Health (NIH, 1998).
years old when they gave birth. Both the American Acad- Maternal practices and knowledge for infant feeding
emy of Pediatrics (AAP) and the National Association of
were assessed by a survey developed from similar questions
Pediatric Nurse Practitioners consider the age of 21 to be
used by Barton (2001). Before administration, the survey
the end of adolescence. The age range of infants was cho-
was critiqued for content and format by two pediatric nurse
sen to capture a sample of young mothers with infantsspecialists and the medical director of maternal–child health
who were old enough to be eating foods. Women were for a local health department, a medical center dietician, and
excluded if their infant had a chronic health or nutrition-
the director of the local WIC clinics. The survey included
al condition that affected the infant’s eating behaviors or
a single 24-hour diet recall and questions about initial
health status (e.g., cleft lip or palate, Down syndrome,
type of infant feeding; current type of feeding; reasons for
cystic fibrosis, and/or cerebral palsy). discontinuation of breastfeeding; sources of support; type,
Informed consent or assent was obtained in a private
number, and quantity of feedings; timing of introduction of
space in the clinical area before an individual interview
solid foods; and the quantity of additional nonmilk bev-
with each mother either before or after a scheduled well-
erages in the infant’s diet, including water intake. Average
baby appointment or a WIC recertification visit. Mothers
daily fluid intake of the infants was determined from the
received compensation in the form of a $10 gift card for
24-hour diet recall histories. To help mothers best estimate
completing the interview. Personal and sociodemographic
quantities of liquids and portions of foods, several sizes
characteristics collected included maternal age, height and
of bottles, “sippy cups,” and baby food jars were available
weight, identified ethnic group, marital status, household
as examples, along with measuring spoons and cups. Ad-
ditionally, the mothers were asked general ques-
Table 1. Maternal and Infant Characteristics (N = 67) tions related to the timing and introduction of
foods for infants (e.g., How do you mix the for-
Characteristic M (SD) Range
mula?, When should a baby start drinking cow’s
Maternal age 19.5 years (1.5) 15-22
milk?, When should you start a baby on eggs?).
Maternal education 12 years (1.4) 8-16 All data were entered into an SPSS (Version
Infant age 8.45 months (2.3) 13) for analysis. Frequency distributions were
Infant gestational age 39 weeks (2.6) 30-42 used to summarize nominal and ordinal data;
Characteristic Frequency % n means and standard deviations were used for
Race/ethnicity continuous data.
• African American 65.7 44
Results
• White 28.4 19
Complete data were obtained from 67 young
WIC 79 53 women between 15 and 22 years of age (M =
Household income ≤ 25,000 76 50 19.5 years, SD = 1.5). Their infants ranged be-
Maternal body mass index tween 6 and 12 months of age (M = 8.5 months,
• Underwieght 6 4 SD = 2.3). Table 1 provides an overview of ma-
• Normal weight 41.8 28 ternal and infant characteristics. The majority of
women had completed high school and identi-
• Overweight 25.3 17
fied themselves as African American (65.7%).
• Obese 26.9 18
Over 75% of the young women reported living
WIC = Women, Infant, and Children. in households with an annual income under
$25,000. The majority (61.2%) of the infants
Table 2. Infant Feeding Practices of Young Mothers were female, products of full-term deliveries,
Frequency % n
and reportedly in excellent health. Most (79%)
of the infants were enrolled in the WIC program.
Attempted to breastfeed 50.7 34
BMI values for the mothers ranged from 17.23
Breastfed at least 6 months 29 10 to 49.24, with a mean score of 26.74 (SD 7.3).
Incorrectly prepared formula 27 18 The majority (52%) of the sample had a BMI
Gave ≥ 6 ounces of juice a day 45 30 >25 (e.g., defined as overweight), with 26.9% of
Gave ≥ 8 ounces of water a day 66 44 the women having a BMI >30, which would cat-
Gave ≥ 32 ounces of formula/milk a day 37 25 egorize them as obese per NIH guidelines.
Put cereal into bottle 79 53
Started solid foods at 4-6 months of age 87 57 Initial Infant Feeding Practice
Unaware of contraindications of: Table 2 presents some of the infant feeding prac-
tices found. About half (n = 34; 50.7%) report-
Eggs 76 51
ed attempting to breastfeed their infant; 10
Honey 64 43
mothers (29.4%) reported breastfeeding up to
Peanut butter 57 38
or last 6 months of age, with two of these moth-
Fed infant in front of TV 58 28 ers breastfeeding their infants until 1 year of age
100 volume 36 | number 2 March/April 2011

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
and one reporting that she planned to Figure 1. Servings of Fruits & Vegetables
breastfeed until at least 1 year of age
(her infant was 6 months old at the 10
time of the interview). At the time of 9
the interview, a majority of the infants 8 0

Number of Infants
were predominately drinking either 7 1
formula or cow’s milk (92.5%, n = 62). 6 2
Attempts to quantify the amount of 5 3
breast milk consumed by infants in a 4 4
feeding through pre- and postfeeding 3 NA
weights were unsuccessful; thus, only
2
quantities of formula or milk are pre-
1
sented. Mean daily intake of formula
0
and/or cow’s milk was 31.5 ounces
(SD 13, range 6–80 oz). In addition to
formula intake, the majority of infants
were also drinking fruit juice and water
on a daily basis. Almost 45% (n = 30)
of the mothers reported that their in-
fants were drinking more than six
ounces of juice a day (M = 6.6 oz, SD 6.0, range 0–32 oz).
Approximately 21% (n = 14) of the mothers reported
giving their infant sips or small amounts of soda, tea,
sports drinks, and/or fruit punches on a daily basis. The
average daily intake of water for the infants was 4.6
ounces (SD 5.1), with some infants not drinking any ad-
ditional water and one drinking as much as 18 ounces a day.
Secondary or Complementary Foods
For this sample, the addition of secondary or comple-
mentary foods began most commonly with the addition of
infant cereal to the bottle (Table 2). Almost 80% (n = 53)
of the mothers reported putting cereal in their infant’s
bottles. A little more than half of the infants (52.8%, n = 28)
were given cereal in their bottle before the recommended
minimum age of 4 months. When asked why they added
cereal to their infant’s bottles, a high proportion of moth-
ers (40.2%, n = 21) responded that their infant was not
full on formula alone and therefore was fussy. In addi-
tion, numerous mothers (23.9%, n =12) reported adding
cereal to the bottle to help the infant sleep longer at
nighttime. Only five mothers (2.7%) reported adding
cereal to the bottle, per healthcare provider advice, to
help with infant reflux or spitting.
Aside from simple infant foods of pureed fruits, vege-
tables, and meats, many of the infants were being fed
additional food from the table. Mashed potatoes and
macaroni and cheese were noted by the majority (56.7%)
of mothers to be foods that they had introduced to their
infants. French fries were frequently reported as a favor-
ite food of infants in this sample. Many of these infants
were fed predominately table food, as long as it could be
mashed to a consistency that could be “gummed” by an
infant. A few mothers (N = 3) also described how they
prechewed table food for their infant to eat. Additional
foods that were noted by the mothers included eggs,
potato chips, cheese puffs, pizza, peanut butter and crack-
ers, ramen noodles, canned sausages, and even crab meat.
Many mothers were unaware of information regard-
ing foods that were potentially allergenic or that may put
their children at risk for infection. For example, when
asked about the timing and process for the introduction
March/April 2011
Number of
servings
6 mos 7-9 mos (N = 21) 10-12 mos
(N = 24) Infant Age Groups (N = 22)
Recommended number of servings a day
of eggs to the diet of an infant, 76% (n = 51) reported
being unaware of any information about allergies. Ap-
proximately 64% (n = 43) were unaware of the appropri-
ate time to wait to introduce peanut butter to their infant,
and only 43.3% (n = 29) were aware of the potential
hazards of introducing an infant under 1 year of age to
honey. Of the mothers who were aware of the risk of
honey, very few could actually verbalize the risk for botu-
lism infection. Mothers just reported knowing that you
should not give an infant honey.
When asked who they turned to for advice and infor-
mation on feeding their infant, the majority (n = 52,
77.6%) of the young mothers reported relying on them-
selves, their mothers, or their grandmothers. Only eight
mothers (11.9 %) reported a healthcare professional as
being the most influential person in advising them how to
feed their infant.
Figure 1 depicts the number of servings of fruits and
vegetables that infants received in a day. Three age groups
were created for comparison purposes. Groupings were
based on the expected number of servings of fruits and
vegetables by age in months based on national recom-
mendations (AAP, 2009; Shelov, 2004). The first group of
infants was 6 months old, the second group included in-
fants 7 to 9 months of age, and the third group included
infants 10 to 12 months old. The majority of infants who
were 6 months of age (N = 24), were being given two or
more servings of fruits and vegetables a day (54.2%,
n = 13). Two infants were not eating anything other than
infant cereal and had not been introduced to any other
solid foods. Of the infants ages 7 to 9 months (N = 21),
only 14.3% (n = 3) of the infants were receiving the recom-
mended amount of fruits and vegetables. Among the 10- to
12-month-old infants (N = 22), only 2 (9.1%) of the in-
fants were receiving the recommended number of fruits
and vegetables. Six (27.3%) of these infants were not
receiving any fruits or vegetables in their diet.
Limitations
The descriptive and cross-sectional nature of this study
limits the ability to identify any causal relationships in-
cluding the effect of the feeding practices on the actual
MCN 101

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Given the relationship between a mother’s
diet and her infant’s diet over time,
nurses should develop interventions
that include strategies aimed at
improving maternal nutrition.
outcome of infant growth. The convenience sample of
young mothers limits the generalizability of the findings
to other samples. In addition, collection of a second diet
recall might have strengthened the reliability of the
mother’s report of their infant’s diet.
Clinical Implications
Findings from this study extend current knowledge re-
garding infant feeding practices of young mothers. Simi-
lar to other studies (McDowell et al., 2008), the incidence
of breastfeeding beyond the early postpartum period was
low. Many of the mothers were giving their infants quan-
tities of formula or milk, juice, and water, which were
higher than national recommendations. Over 40% of the
infants were drinking more than the AAP (2009) recom-
mended 4 to 6 ounces of juice per day. High intake of
juice may lead to unneeded calories and replace needed
nutrients from breast milk and formula. Many mothers
were adding more than the recommended amount of wa-
ter to prepare the infant formula. Young mothers may be
adding additional water to “stretch” limited formula
supplies or use water (and juice) in the place of formula
to calm a crying baby. These findings are consistent from
clinical reports of nurses and other healthcare providers
(Keating, Schears, & Dodge, 1991).
In this study, a majority (54%) of 6-month-old infants
were receiving the recommended amount of fruits and
vegetables, whereas only 14% of 7- to 9-month-old, and
9% of 10- to 12-month-old infants were receiving the
recommended amount. This finding is similar to recent
reports that as infants age, the number of servings of
fruits and vegetables decreases, with 18% to 33% of
infants and young children ages 7 to 24 months eating no
servings of fruits and/or vegetables in a day (Fox et al.,
2004). This finding is consistent with national studies
that identify significant negative changes in the nutrient
balance of young children’s diets, occurring in the first
year of life, identifying a key time for intervention (Dev-
aney et al., 2004; Fox et al., 2004; Skinner et al., 2004).
Results from this study suggest that infant diets mirror
maternal diets and eating habits as early as 7 months of
age. Consistent with previous studies (Lee, Hoerr, &
102 volume 36 | number 2
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Schiffman, 2005), maternal dietary quality may be an ef-
fective proxy or assessment of the nutritional quality of
their infant’s diet. This is concerning, as a majority of the
young mothers (52%) in this sample already had a BMI
>25. Many of the mothers (58%) reported feeding their
infants essentially what they were eating and often while
watching television. In this study, the shift from a bal-
anced diet including adequate fruits and vegetables toward
less nutrient-dense foods occurred at approximately 7 to
9 months of age.
A majority (79%) of the infants in this study were
enrolled in the WIC program. The goal of the WIC pro-
gram is to improve the diets of infants and children by
providing supplemental foods and nutritional education
for mothers (Ponza, Devaney, Ziegler, Reidy, & Squatrito,
2004). Despite the focused efforts of WIC, study findings
reported here suggest that some mothers have inadequate
knowledge and skills related to infant feeding. However,
poor infant diets may also reflect an inadequate level of
food security (Casey et al., 2006). For many of these
low-income mothers, limited or uncertain access to
enough nutritious food may be a very real concern and
be reflected in the dietary habits of their household. Re-
sources, such as WIC, are only supplemental and young
mother’s feeding practices may be their best attempts to
feed their child within their means.
Nurses need to be concerned about how to use the re-
sults of this study to best help young mothers and their
infants. Given the relationship between a mother’s diet
and her infant’s diet over time, we believe that nurse-
developed interventions to promote early healthy infant
feeding practices must include strategies aimed at in-
creasing maternal nutrition. Nurses can use this study to
reinforce the need to work closely with young mothers to
teach the appropriate preparation of formula, the balance
of liquids in their infant’s diet, and how to appropriately
identify and respond to infant cues.
Based on the number of inappropriate and unsafe feed-
ing practices noted in this sample, many young mothers
may be receiving incorrect and sometimes dangerous in-
formation about what to feed infants. This finding under-
scores the importance of including others aside from the
mother in nutritional teaching at well-infant visits, such
as grandmothers and other family members who provide
Clinical Implications
Nurses who work with young mothers and their
infants should:
• Include strategies aimed at improving maternal
nutrition in order to help improve infant nutrition.
• If formula is being used, teach the appropriate
preparation of formula, the balance of liquids in
infant’s diet, and how to identify and respond to
infant cues of hunger.
• Include influential family members such as grand-
mothers and other family members in the teaching
plan, especially if they are involved with infant care
and meal preparation.
• Consider referrals to resources such as home visita-
tion programs, telephone help lines or food banks.
March/April 2011
infant care and may be involved in actual meal preparation.
In addition, it is important to remember that inappropri-
ate feeding practices may reflect inadequate knowledge,
but could also be a sign of inadequate food security
(Casey et al., 2006). Making referrals to available com-
munity supports and resources such as home visitation
programs, telephone help lines, or food banks should be
considered for young mothers.
Future Research
Study findings highlight the need for longitudinal studies
to assess infant feeding practices and the actual influence
on infant growth measures. Qualitative strategies such as
focus groups or in-depth individual interviews may also
help identify key factors not yet delineated, which may
influence mothers as they seek to make choices about
their and their infant’s diet and health. More studies are
needed to better understand how young mothers decide
what and when to feed their young infants and who influ-
ences their decision making. Future studies would also ben-
efit from the addition of a specific measure of household
food security to further identify contextual factors that may
be influencing young mother’s infant feeding practices. ✜
Sharon M. Karp is an Assistant Professor, Vanderbilt Uni-
versity, Schools of Nursing and Medicine (Pediatrics). She
can be reached via e-mail at sharon.karp@vanderbilt.edu.
Melanie Lutenbacher is an Associate Professor, Van-
derbilt University, Schools of Nursing and Medicine
(Pediatrics).
This research was funded by a grant from the Vander-
bilt University School of Nursing, Iota Chapter of Sigma
Theta Tau International.
The authors have disclosed that there are no financial
relationships related to this article.
DOI:10.1097/NMC.0b013e31820558bf
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ONLINE
The American Academy of Pediatrics (AAP)
www.aap.org/
Bright Futures
www.brightfutures.org/
Unites States Department of Agriculture
(USDA)- MyPyramid.Gov
www.mypyramid.gov/guidelines/
USDA-National Agricultural Library
http://fnic.nal.usda.gov/nal_display/index.php?info_
center=4&tax_level=2&tax_subject=257&topic_id=1352
USDA—Food & Nutrition Service
Women, Infants and Children (WIC) Program
www.fns.usda.gov/wic/
The Children’s Hospital of Philadelphia
www.chop.edu/
The March of Dimes
www.marchofdimes.com/
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