Feeding and dietary practices of New Zealand infants : an observational study : a thesis presented in the partial fulfilment of the requirements for the degree of Doctor of Philosophy in Nutritional Science at Massey University, Albany, New Zealand
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2023
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Massey University
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Background: Nutrition and early-life feeding practices have short and long-term impacts on the quality and longevity of life. The importance of optimal nutrition during infancy is recognised worldwide and evidence-based infant feeding recommendations have been developed to promote infant health, growth, development, and the establishment of healthy eating behaviours. Currently, there is limited evidence on infant nutrition and feeding practices in New Zealand (NZ), with gaps in our knowledge about what infants are being fed, adherence to the Ministry of Health (MoH) ‘Healthy Eating Guidelines for New Zealand Babies and Toddlers (0–2 years old)’, and the prevalence of concerning feeding behaviours (CFB).
Aim: To 1) investigate the contributions that key foods and food groups make to the dietary intake of NZ infants, 2) investigate infant adherence to key dietary indicators as recommended by the MoH’s ‘Healthy Eating Guidelines for New Zealand Babies and Toddlers (0–2 years old)’, and 3) determine the prevalence of parent-reported concerning infant feeding behaviours and associated demographic characteristics and feeding practices of NZ infants between 7.0 and 10.0 months of age.
Methods: The observational First Foods NZ (FFNZ) study recruited 625 ethnically diverse infants (aged 7.0 to 10.0 months) living in Auckland and Dunedin between July 2020 and February 2022. Caregivers who were 16 years or older, spoke English, and had not recently participated in a nutritional intervention that may have influenced their infant’s diet were invited to attend two study visits. Appointments were conducted in the participant’s home, available research centre, or via Zoom (during Covid19 restrictions for second appointment only) and included two 24-hour diet recalls and demographic and feeding questionnaires. Diet recall data were analysed through FoodWorks (Version 10, Xyris Software, Australia) using the NZ Food Composition Database FOODfiles™ 2018 Version 01, and foods were allocated food and food group codes using the FFNZ coding system. Counts of foods and food groups consumed were analysed for at least one and both diet recall days, where available. Key indicators from the MoH’s ‘Healthy Eating Guidelines for New Zealand Babies and Toddlers (0–2 years old)’ that were measurable from FFNZ data and applied to those aged 7.0 to 10.0 months were extracted from questionnaire data, or where stated from 24-hour recalls. Recommendations analysed included exclusive breastfeeding to ‘around’ six months of age (defined as ‘5 months’ or ‘6 months’, being the age when something other than breast milk, i.e. either another drink, or solid foods, was first introduced); current breastfeeding; the introduction of solid foods ‘around’ six months of age” (defined as ‘5 months’ or ‘6 months’ when the first solid food was introduced); the introduction of puréed foods and spoon-feeding when starting solid foods; offering of iron-rich foods (meat, poultry, fish, seafood, and iron fortified infant cereals), vegetables, and fruit as first foods; the daily offering of MoH food groups (24-hour recall data; vegetables, fruit, grain foods, milk and milk products, and meat and protein-rich foods); no salt and sugar added to meals (specific 24-hour recall question); avoidance of inappropriate drinks (specific 24-hour recall question; beverages other than breast milk, formula, or water such as cow’s milk as a drink, other milk, juice, soft drinks, tea, and alcohol); and use of self-feeding when developmentally appropriate. Logistic regression was then used to estimate odds ratios, 95% confidence intervals, and p-values for associated sociodemographic characteristics and key indicators. After their second appointment, caregivers were emailed a final questionnaire, which included the Paediatric Eating Assessment Tool (PediEAT). Feeding behaviours were categorised according to the total PediEAT and subscale scores (physiologic symptoms, problematic mealtime behaviours, selective/restrictive eating, and oral processing). Scores were categorised as ‘concern’ and ‘no concern’ using the PediEAT scoring system. Unpaired t-tests and the chi-squared tests determined associations between PediEAT scores and infant and caregiver sociodemographic characteristics. Logistic regression, adjusted by infant age and deprivation, determined associations between PediEAT scores and food groups consumed during both diet recalls. Data were analysed using Stata software (StataCorp, Texas) and Microsoft Excel (version 16.66).
Results: Written consent was obtained from 625 caregivers. Data from the demographic and feeding questionnaire were available from all infants (n=625). All caregivers completed at least one diet recall. A second diet recall was available from 614 infants. PediEAT results were available for 554 term infants.
Most infants consumed vegetables (96.2% of infants), fruit (91.8%), grain foods (90.4%), milk and milk products (64.0%), and meat and protein-rich foods (84.3%) at least once during the two 24-hour diet recall days. Commercial infant foods (CIF) were consumed by 78.1% and discretionary foods by 56.3% of infants at least once. The proportion of infants who consumed vegetables (63.2%), fruit (53.9%), grain foods (49.5%), milk and milk products (38.6%), meat and protein-rich foods (31.8%), CIF (41.8%), and discretionary foods (16.1%) on both diet recall days was lower. Overall, only 6.5% of infants met guidelines for the daily consumption of the MoH food groups. The ten most common foods consumed were carrot, banana, bread, brassicas, kumara, extruded commercial infant snacks, pumpkin, apple, potato, and commercial infant pouches.
Breastfeeding was initiated by 97.2% of mothers, and 37.8% of infants were exclusively breastfed to around six months. At the time of participation, 66.2% of infants were breastfed. Most infants met guidelines for introducing solid foods, including the age of introduction (75.4%), offering iron-rich foods as first foods (88.3%), providing puréed textures (80.3%) and spoon-feeding (74.1%). Self-feeding at the time of participation was common (86.9%). Most met guidelines for avoiding inappropriate beverages (93.9%) and adding salt (76.5%) and sugar (90.6%) to foods. Typically, infants with caregivers who were younger, higher educated, not currently working, primiparous, and living in low deprivation were more likely to meet the guidelines.
Feeding behaviour scores were higher than PediEAT norm-reference values and 17.3% of infants were categorised with ‘concern’ feeding behaviours. ‘Concern’ scores were highest for selective/restrictive eating (29.2%), problematic mealtime behaviours (21.5%), and physiologic symptoms (13.7%) subscales. Mothers who were primiparous and highly educated caregivers were more likely to report ‘concern’ total PediEAT scores. Primiparous mothers and caregivers with higher education, that did not use early child education centres, and had infants of NZ Asian infant ethnicity were more likely to report problematic mealtime behaviours. Infants characterised as of ‘concern’ had significantly lower odds of consuming ‘vegetables’ and ‘meat and protein-rich foods’ and were more likely to consume ‘CIF’. Infants with problematic mealtime behaviours had a lower odds of consuming ‘discretionary foods’ and were more likely to be still breastfeeding.
Conclusion: This research provides evidence on infant food and food group intake, adherence to key MoH infant feeding guidelines, and the prevalence of parent-reported infant feeding behaviours and associated demographic characteristics and feeding practices from an ethnically diverse group of NZ infants from Auckland and Dunedin. Infants were shown to consume a range of foods within the MoH food groups at least once during the study. However, only 6.5% of infants consumed all five food groups during both recalls. Grain foods, milk and milk products, and meat and protein-rich foods were the least commonly consumed food groups when investigating those consumed on both recall days, increasing the risk of nutritional deficiencies. Most infants met guidelines for introducing solid foods and avoiding inappropriate beverages and adding salt and sugar to meals, although the prevalence of exclusive breastfeeding to ‘around’ six months, however, continues to be low, particularly for first-time mothers. As seen previously, sociodemographic characteristics were also associated with adherence, identifying key groups (primiparous mothers, lower educated caregivers, those living with multiple children, and those living in areas of high deprivation) that require additional support. Finally, CFB were prevalent in our study, with higher scores reported by primiparous mothers and caregivers who were highly educated. Infants with CFB were less likely to meet recommendations for ‘vegetables’ and ‘meat and protein-rich foods’ and were more likely to consume ‘CIF’. Further investigation is required to understand parental perceptions of feeding behaviours and the nutritional implications of CFB. Further research will determine the nutritional implications of not meeting the MoH food group guidelines during complementary feeding, investigate what support parents need in NZ to improve adherence to the MoH breastfeeding and food group recommendations, and the impact of CFB on nutrient intake.
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Infants, Nutrition, Breastfeeding, Questionnaires, Evaluation, New Zealand