Baby and toddler nutrition: Qualitative research with key ethnic minority groups

Current Early Feeding Behaviour

1. Across the ethnic sample, a high proportion of women had breastfed their babies; many until their babies were at least three months old, demonstrating relatively high awareness of the health benefits of breast feeding.
2. Most mothers had introduced first solids before the current recommended six month threshold, a majority starting at around four to five months. However, a small minority claimed to have introduced solids around three months. Very few mothers adhered to the six month guideline despite high awareness of this across the sample.
3. The rationale for early introduction of first solids was similar to that offered by the mainstream sample. Most mothers reported that they had responded to their infants’ (perceived) need for more than milk because their infants appeared to be hungrier and more restless.
4. In addition, to this primary aim of satisfying their infants’ perceived needs, the ethnic sample were also motivated by the desire to introduce infants to their own cultural foods as quickly as possible.  This was driven by the fact that these foods were perceived to be healthy and that mothers generally wanted their infants to acquire a taste for traditional cultural foods so they could progress to family meals as soon as possible.  These foods were adapted by some mothers to cut out salt and spices but others offered these unaltered in the belief that infants needed to get used to the taste of family foods.
5. Amongst more traditional households, the desire for large babies was still prevalent and some mothers felt pressurised by older family members to introduce solids before six months and to over-feed their infants with calorie laden milk and foods. This was observed across the five ethnic groups.
6. Amongst some Bangladeshi, Pakistani and Indian mothers, babies were hand fed for longer, even when infants were able to grasp and chew unaided. This resulted in instances of overfeeding and forced feeding. There was also a preference for sweet early foods such as sweet rice and egg custard for some and a high value was also placed on milk, suggesting that milk was not always progressively reduced as solids and drinks were incorporated into infants’ diets. There was greater usage of commercial baby foods amongst more traditional families who perceived these to be of high quality.
7. Amongst the Black African and Black Caribbean sample, there was a tendency to add foods such as cornmeal, maize and the commercial cereal, Cerelac, to thicken infants’ milk feeds from about two months. This was common practice amongst these communities as a means of satisfying infants’ hunger and to aid sleep. There was also a preference for savoury foods and infants were often given traditional soups and pureed stews as early foods. There was generally lower usage of commercial baby foods beyond first foods amongst these communities.

Awareness of Safe Early Feeding Guidelines

Six Month First Feeding Threshold

1. As with the mainstream sample, a majority of the sample were aware of the six month threshold for the introduction of first solids, even amongst those women with poor English language skills. Key sources for this information were health professionals, Bounty packs and the general media. However, there was relatively low understanding of the reasons for this guideline and the higher risks of allergies and infection of introducing first solids before six months.
2. Mothers with older children were generally aware of the previous four month guideline for the introduction of solids.
3. A number of reasons were offered by the sample to explain the low take up of the six month guideline: mothers’ beliefs that their babies were ready for first solids, no health risks associated with the early first feeding of previous infants, pressure from family influencers to start, a desire to introduce cultural foods, the lack of emphatic discouragement by health professionals and that food labelling by commercial baby food manufacturers appeared to support first feeding before six months.

Safe Early Foods

1. There was some awareness of the foods to avoid for infants under six months old. These were mainly those with known and publicised health risks (e.g. eggs). However, a number of mothers were less clear about other recommended foods to avoid, especially those that were traditionally part of early baby foods e.g. wheat.
2. There was relatively good understanding of the main risk foods, such as salt and sugar, to avoid with infants under one year old. However, there was some confusion about other foods given as babies progressed from milk only to solids which were deemed to be part of the sample’s cultural foods such as spices (in terms of which specific spices could safely be given and those that are recommended to be avoided), wheat and honey.
3. For most mothers, there was little real understanding of why they should avoid certain foods. As a result, many mothers followed the feeding behaviour they had adopted with older children or the advice offered by family influencers.

Introduction of Drinks

1. Water was given to babies for a number of reasons and was often introduced as early as a few weeks after birth. Water was offered when babies appeared thirsty or in place of milk during the night to discourage night waking. There was good awareness of the long term benefits of encouraging infants to drink water. However, some mothers added honey, diluted baby juice and diluted adult juices to help babies acquire a taste for water. Most mothers did not necessarily perceive this to be inappropriate.
2. There was good understanding of the risks of teeth damage by giving too much fruit juice to infants amongst some mothers. However, others were offering high amounts of juice in the belief that these were healthy and appropriate.
3. With respect to milk, there was some evidence of the early introduction of cow’s milk as a main drink, as early as six months for a few mothers. There was little real knowledge as to why this was not recommended by the Department of Health amongst these mothers.

Commercial Baby Foods

1. For almost all mothers, commercial baby foods were the first foods to be introduced. This included baby rice and cereals. However, some mothers continued using branded baby foods whilst others moved onto other early solid foods.
2. In store purchasing behaviour largely mirrored that of the mainstream sample. Most mothers had a menu of tried and tested brands and within these they did seek out new flavours, formats and offers. This was largely driven by a desire to provide their infants with variety and new tastes.

Setting Healthy Eating Foundations

1. A majority of mothers in the sample understood the need to set healthy eating habits for the future. A number of ‘components’ were offered as indicators of a healthy infant diet. This included: offering fresh fruit and vegetables, mainly home cooked meals, avoiding salt and sugar, the importance of variety, textures and flavours, water and milk for growth and healthy finger foods and snacks as babies developed.
2. The sample also suggested that infants needed feeding routines, to sit with the family at mealtimes, to play with food, to have limited and healthy in-between meal snacks and appropriate food portions. These were reported as important to ensure infants became interested in food in general and family foods in particular, and avoided infants becoming fussy eaters.
3. However, many mothers found it hard to adhere to these good intentions and they tended to fall by the wayside as babies became toddlers. At this stage, snacking on unhealthy savoury and sweet treats was more evident as was the introduction of Western ‘junk’ foods. We saw evidence of snacking on these foods in between meals amongst toddlers from the age of about eighteen months. There appeared to be limited appreciation of the long term health risks on the infants’ health of such foods amongst some mothers.
4. The key barriers to setting healthy eating foundations were the lack of specific knowledge of how to translate health messages into actual practice, pressure from family influencers to give inappropriate foods and snacks in large portions, lack of ideas for variety and infants being exposed to inappropriate and less healthy family diets.

Differences in Early Feeding Behaviour

1. As with the Ethnic Minority Childhood Obesity research, the TNS mainstream childhood obesity clusters were not appropriate for this sample. However, a number of typologies were observed based on overall attitudes to early feeding and actual behaviour.
2. ‘Traditional Cooks’ were largely older mothers in the sample who were typically introducing first foods to their babies earliest, often at around two and a half months. There was a strongly held belief that feeding before six months would prevent fussy eaters in the future and that it was important to encourage infants to enjoy unaltered family meals as early as possible. There was little monitoring of salty and sweet snacks and treats as infants developed in the general belief that as long as ‘healthy’ cultural foods were eaten, there was little need to restrict other foods. These mothers were largely guided by the advice of their mothers and strongly believed that the approach offered by them was the ‘right’ one. There was little understanding of the need to adapt cultural foods or for balance in the foods given to toddlers.
3. ‘Modern Adapters’ tended to be of higher socio economic groups. They were quite knowledgeable about healthy eating and were typically introducing first foods at around five months. They were very much motivated by doing what was best for their babies and were actively trying to ensure that their infants were as healthy as possible. Their strategies included giving lots of fresh fruit and vegetables and home prepared and cooked foods with no added salt and spices. They were also trying to introduce healthy snacks and finger foods. These mothers were generally getting advice and information from a variety of sources but then made up their own minds of what was appropriate for their infants. They were largely able to handle pressure from female family members for less healthy early feeding approaches. These mothers were interested in finding out how they could ensure that their babies had the best diets possible.
4. “Anxious Feeders’ were primarily the most traditional women in the sample and represented many of the clients seen by health professionals. They were typically from low socio economic group households, had low education levels and English skills. There was greater dependence on commercial baby foods as these were seen by mothers and their influencers to be the best. There was also: an over-dependence on sweet early foods, babies were often bottle fed for longer, infants were hand fed for longer and toddlers were typically over indulged with unhealthy Western and cultural sweet and savoury snacks. There was little understanding of the long term health risks (of, for example, childhood obesity) of inappropriate early feeding practices.
5. ‘Educated Home Cooks’ in the sample were typically from vegetarian households. They were largely following safe early feeding practices. They were usually breast feeding for longer, starting to introduce first foods later, were feeding infants on fresh home prepared and cooked foods and adapting family foods (i.e. not salt and spices). However, there was some concern about whether their home meals were providing enough variety and nutrients.

Typologies: Key Communication Needs

Underlying the differences in feeding behaviour amongst the four typologies were differing sets of communications needs. These can be summarised as follows:

Feeder Type

Key Motivations

Key Intervention Needs

Traditional

Cooks

‘My food is the best:

baby adapts to our food not the other way round’

Rationale for adapting cultural foods

Need for balance and healthy snacks for toddlers

Modern

Adapters

‘Adapting to baby’s need as best I can’

How to ensure variety with home cooked foods (rather than commercial)

More recipe ideas (cultural and Western)

Anxious Feeders

‘West is best’

Sweet foods (Asians)

High starch/carbohydrate

(African/Caribbean)

Challenge value of commercial (expensive)

Encourage more healthy cultural foods

Challenge food myths (e.g. honey)

Educated Home

Cooks

‘Fresh home cooked is best’

Variety, balance (esp. for vegetarians)

Responses to Intervention Ideas & Stimuli

1. A number of intervention ideas and stimuli were developed to test in the mini group discussions. These were based on encouraging: introduction of first foods at six months, the introduction of transition foods at the appropriate stages of development, healthy snacks and finger foods and testing awareness of the reasons for the six month threshold and the recommended ‘safe’ early foods.
2. Responses to the recipe booklet were largely positive across the sample. It was considered to be easy to follow, colourful and well laid out. The booklet provided recipes and recipe variations giving mothers food ideas they may not have considered offering their babies and toddlers. There was interest in cultural recipes to expand the repertoire of these foods given as well as in Western recipes as a means of ensuring a varied and healthy early diet.
3. A calendar was tested providing information on: appropriate foods for baby and toddler meals, a list of foods that could be safely given, foods to avoid and appropriate drinks at each stage of transition from milk only to solids. Many mothers responded positively to this intervention as an easy reference for baby and infant meal time ideas. The list of ‘safe’ foods was generally perceived to be useful. However, some felt the tone was too emphatic and, therefore, dictatorial.
4. A list of healthy snacks and finger foods was presented as a possible fridge magnet idea. While this was relevant for most women, some recommended that including cultural finger foods could make it more useful and relevant. Others suggested extending this idea into a plate, showing a balance of food groups that could make up a healthy diet for babies and toddlers.
5. The rationale behind the six month guideline was presented to the mini group sample. Responses were quite negative as a majority of mothers claimed not to be convinced of the science behind the guideline. As a result, many mothers claimed that they would continue with their current early feeding practices.
6. A list of appropriate first and transition foods was shown to women to gauge levels of awareness and attitudes to these. A majority of the sample were aware of some of the key foods to avoid, particularly those that had been publicised as ‘risk’ foods, but not all. Also, not all understood why certain foods were not recommended as safe. 
7. Pages from a website specifically targeting the South Asian community, based in the Indian sub-continent were shown to the Pakistani, Bangladeshi and Indian sample. Overall, feedback was positive: the site was seen to provide good levels of information on when to introduce first foods, appropriate cultural first foods and suitable transition foods. However, there was a view that it would need to be adapted specifically for the cultural and information needs of the Bangladeshi, Pakistani and Indian communities in the UK.

Health Professionals’ Perspective

1. Overall, feedback from health professionals confirmed findings from the ethnic sample in terms of what they had observed of current early feeding behaviours amongst their ethnic client base.
2. Most health professionals believed that their advice was valued but this was typically taken as a reference point. Although most mothers were keen to do what was in the best interests of their babies, they were eventually lead by perceptions of their babies’ individual needs and the influence of key relatives.
3. Health professionals often felt ill-equipped to deal with the specific issues of these ethnic minority communities, particularly mothers from traditional households. This partly because of a lack of appropriate and targeted resources.
4. Health professionals felt that the changes in the guidelines made it harder to ‘sell’ the six month first feeding recommendation. They generally felt that mothers found it easier to ignore this advice, particularly as health professionals themselves did not have detailed knowledge of the science behind the guideline to counteract this. They also felt that foods considered as high risk by the Department of Health often led to confusion and misinterpretation so mothers were often unsure why they should change their early feeding behaviour.
5. Health professionals who were not from the target ethnic communities struggled to cope with the lack of English language skills especially amongst their South Asian clients. Also, mainstream communications and concepts were not always relevant or appropriate for mothers from these communities. Many health professionals also felt that they were hindered by their lack of understanding of the cultural issues behind feeding practices amongst their clients.
6. Health professionals themselves did not necessarily adhere to the early feeding guidelines. As a result, they often found it difficult to actively discourage mothers who did not follow these guidelines, particularly for infants who seemed ready for first solids before six months.
7. As a result of the above issues, health professionals in the sample found it difficult to convey the six month message in a meaningful way and focussing on other safe early foods/feeding messages were felt by some to be easier to communicate and promote if they had the ‘science’ behind these as ‘ammunition’.