Copyright is owned by the author of this thesis. Permission is given for a copy to be downloaded by an 

individual for the purpose of research and private study only. The thesis may not be reproduced 

elsewhere without the permission of the author. 

 

 

 

 

 

 

 

 

 

 

 

 



  

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 

 

 

Kimberley Jane Brown 

 2023 

  



 

 

 

I 

ABSTRACT 

 

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 



 

 

 

II 

 

 

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. 



 

 

 

III 

 

 

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 



 

 

 

IV 

 

 

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.   



 

 

 

V 

 

 

ACKNOWLEDGEMENTS 
 
It has been a privilege to be a part of this study and to have been awarded the Health Research Council of 

New Zealand doctoral scholarship. I would love to take this opportunity to express my gratitude to all of 

those involved in this research. No matter your role, this research would not be possible without your 

contribution.  

Firstly, I would like to thank our caregivers and infants who participated in the study. To connect with you 

all during such a special time of your lives was an invaluable experience. Thank you for welcoming us into 

your lives and I wish you all the best for your journeys to come.  

To my academic supervisors, Cathryn Conlon, Pamela von Hurst, and Kathryn Beck, thank you for your 

ongoing guidance and support during the past three years. Without your critique and expertise, the 

development and evolution of this thesis would not have been possible.  

To Anne-Louise Heath and Rachel Taylor, thank-you for promoting the need for further infant research in 

New Zealand and providing the opportunity to be part of the First Foods New Zealand Team. Working with 

you both has been an honour. To my fellow Auckland First and Young Foods New Zealand PhD candidates, 

Maria Casale, Rio Monzales, and Emily Jones, working with you for the past three years has been a fantastic 

experience. Thank you all for your dedication to the study. You are inspiring individuals, and I look forward 

to seeing where your journey takes you next. To Rebecca Paul and Jenny McArthur, thank you for your 

indispensable project management during data collection. The day-to-day running of data collection would 

not have been possible without you both. To the Auckland research assistants, Andrea Wei, Emily Shoesmith, 

and Darrian Holten, data collection would not have been the same without you. Thank you for your 

contribution to our study. To Lizzie Jones, Ioanna Katiforis, Andrea Wei, Neve McLean, Rebecca Paul, and Liz 

Fleming, thank you for your time spent during FoodWorks data entry and quality checking. Working with 

you all was a great experience. To Ioanna Katiforis and Liz Fleming, thank you for your assistance in 

developing and implementing the First Foods New Zealand food coding system – a mammoth task that has 

allowed insight into crucial areas of infant nutrition in New Zealand. To Jillian Haszard, thank you for your 

statistical support and patience during data analysis. I have learnt a great deal from you. To the remaining 

University of Otago and Massey University teams, thank you for your invaluable input into the study. It was 

a pleasure working with you all.  

And finally, to my friends and family, thank you for your ongoing love and support. Your continual 

encouragement has allowed me to achieve various career milestones during the past three years. To my 

parents, Jenny and Hamish, I send my deepest appreciation for your continued support and encouragement. 

I could not have achieved this work without you.   



 

 

 

VI 

 

 

  TABLE OF CONTENTS   
 

ABSTRACT ..................................................................................................................................................................... I 

ACKNOWLEDGEMENTS ............................................................................................................................................. V 

TABLE OF CONTENTS ................................................................................................................................................ VI 

LIST OF TABLES ........................................................................................................................................................... IX 

LIST OF FIGURES ......................................................................................................................................................... XI 

LIST OF ABBREVIATIONS AND SYMBOLS ................................................................................................................ XII 

LIST OF PAPERS AND CONFERENCE PRESENTATIONS .......................................................................................... XIV 

CHAPTER 1: AN INTRODUCTION TO THIS RESEARCH ............................................................................................. 1 

1.1. INTRODUCTION AND JUSTIFICATION FOR THE STUDY ............................................................................... 2 

1.2. THESIS AIMS .................................................................................................................................................. 7 

1.3. THESIS OBJECTIVES ....................................................................................................................................... 7 

1.4. STUDY HYPOTHESES ..................................................................................................................................... 8 

1.5. THESIS STRUCTURE ....................................................................................................................................... 8 

1.6. RESEARCHER CONTRIBUTIONS .................................................................................................................... 9 

1.7. REFERENCES ................................................................................................................................................ 13 

CHAPTER 2: A REVIEW OF THE CURRENT LITERATURE ........................................................................................ 22 

2.1.        INFANT FEEDING GUIDELINES ..................................................................................................................... 23 

2.1.1. A GLIMPSE INTO THE HISTORY OF INFANT NUTRITION ............................................................................ 23 

2.1.2. THE NEW ZEALAND MINISTRY OF HEALTH INFANT FEEDING GUIDELINES .............................................. 27 

2.1.3. COMPARING THE NEW ZEALAND INFANT FEEDING GUIDELINES TO GLOBAL GUIDELINES AND THOSE 

FROM HIGH INCOME COUNTRIES ........................................................................................................................ 33 

2.2. ASSESSING THE DIETARY INTAKE OF INFANTS .......................................................................................... 50 

2.2.1. ADHERENCE TO INFANT FEEDING GUIDELINES IN HIGH-INCOME COUNTRIES ....................................... 51 

2.2.2. FACTORS ASSOCIATED WITH INFANT DIETARY INTAKE IN HIGH-INCOME COUNTRIES .......................... 57 

2.3. FEEDING BEHAVIOURS ............................................................................................................................... 61 

2.3.1. MEASURING FEEDING BEHAVIOURS ......................................................................................................... 62 



 

 

 

VII 

 

 

2.3.2. INFLUENCES ON FEEDING BEHAVIOURS ................................................................................................... 68 

2.3.3. THE RELATIONSHIP BETWEEN FEEDING BEHAVIOURS AND DIETARY INTAKE ......................................... 69 

2.4. CONCLUDING STATEMENT ......................................................................................................................... 70 

2.5. REFERENCES ................................................................................................................................................ 72 

CHAPTER 3: CONTRIBUTIONS OF KEY FOODS AND FOOD GROUPS TO THE DIETARY INTAKE OF INFANTS IN 

THE FIRST CFOODS NEW ZEALAND STUDY ........................................................................................................... 101 

3.1. ABSTRACT ................................................................................................................................................. 102 

3.2. INTRODUCTION ........................................................................................................................................ 103 

3.3. METHODS .................................................................................................................................................. 105 

3.4. RESULTS .................................................................................................................................................... 109 

3.5. DISCUSSION .............................................................................................................................................. 117 

3.6. CONCLUSION ............................................................................................................................................ 123 

3.7. REFERENCES .............................................................................................................................................. 124 

CHAPTER 4: ADHERENCE TO INFANT FEEDING GUIDELINES IN THE FIRST FOODS NEW ZEALAND STUDY ...... 128 

4.1. ABSTRACT ................................................................................................................................................. 129 

4.2. INTRODUCTION ........................................................................................................................................ 130 

4.3. METHODS .................................................................................................................................................. 133 

4.4. RESULTS .................................................................................................................................................... 141 

4.5. DISCUSSION .............................................................................................................................................. 154 

4.6. CONCLUSION ............................................................................................................................................ 159 

4.7. REFERENCES .............................................................................................................................................. 161 

CHAPTER 5: PARENT-REPORTED FEEDING BEHAVIOURS OF NEW ZEALAND INFANTS AND ASSOCIATIONS 

WITH DEMOGRAPHIC CHARACTERISTICS AND FEEDING PRACTICES IN THE FIRST FOODS NEW ZEALAND 

STUDY………………………………………………………………………………………………………………………………………………………………167 

5.1. ABSTRACT ................................................................................................................................................. 168 

5.2. INTRODUCTION ........................................................................................................................................ 169 

5.3. METHODS .................................................................................................................................................. 171 

5.4. RESULTS .................................................................................................................................................... 174 

5.5. DISCUSSION .............................................................................................................................................. 182 



 

 

 

VIII 

 

 

5.6. CONCLUSION ............................................................................................................................................ 187 

5.7. REFERENCES .............................................................................................................................................. 188 

CHAPTER 6: CONCLUSIONS AND FUTURE RECOMMENDATIONS ....................................................................... 196 

6.1. STUDY SUMMARY AND ACHIEVEMENT OF AIMS AND OBJECTIVES ....................................................... 197 

6.2. STRENGTHS AND LIMITATIONS ................................................................................................................ 202 

6.3. CONCLUDING REMARKS ........................................................................................................................... 203 

6.4. RECOMMENDATIONS FOR FUTURE STUDIES .......................................................................................... 204 

6.5. REFERENCES .............................................................................................................................................. 205 

APPENDICES ............................................................................................................................................................ 211 

APPENDIX 1: SEARCH STRATEGY ............................................................................................................................ 211 

APPENDIX 2: STATEMENT OF CONTRIBUTION FOR MANUSCRIPTS ...................................................................... 213 

APPENDIX 3: PUBLISHED FIRST FOODS NEW ZEALAND STUDY PROTOCOL PAPER .............................................. 216 

APPENDIX 4: STUDY POSTERS ................................................................................................................................. 224 

APPENDIX 5: STUDY INFORMATION SHEET ............................................................................................................ 226 

APPENDIX 6: STUDY CONSENT FORM .................................................................................................................... 228 

APPENDIX 7: 24-HOUR DIET RECALL STANDARD OPERATING PROCEDURE ......................................................... 231 

APPENDIX 8: 24-HOUR DIET RECALL TEMPLATE .................................................................................................... 237 

APPENDIX 9: FOODS FED BY OTHER ADULTS (FFOA) FORM .................................................................................. 239 

APPENDIX 10: 24-HOUR DIET RECALL PROMPTS ................................................................................................... 242 

APPENDIX 11: 24-HOUR DIET RECALL GRID SHEETS .............................................................................................. 246 

APPENDIX 12: EXAMPLES OF FOOD AND FOOD GROUP CODING ......................................................................... 248 

APPENDIX 13: MAIN QUESTIONNAIRE ................................................................................................................... 252 

APPENDIX 14: FINAL QUESTIONNAIRE (PEDIEAT) .................................................................................................. 287 

APPENDIX 15: NUTRITION SOCIETY CONFERENCE ABSTRACT .............................................................................. 296 

 

  



 

 

 

IX 

 

 

LIST OF TABLES 
 

Chapter 1 

Table 1.1: Candidate research contribution ................................................................................................... 11 

 

Chapter 2 

Table 2.1: Comparison of the 2021 and 2008 New Zealand Ministry of Health Infant Feeding Guidelines ......... 28 

Table 2.2: Infant feeding guidelines identified and used to compare recommendations in high-income countries

 .................................................................................................................................................................. 34 

Table 2.3: Exclusive breastfeeding recommendations from guidelines in high-income countries, according to 

infant age .................................................................................................................................................... 37 

Table 2.4: Optimal breastfeeding recommendations from guidelines in high-income countries, according to 

infant age .................................................................................................................................................... 39 

Table 2.5: Complementary feeding recommendations from guidelines in high-income countries ..................... 40 

Table 2.6: Salt and sugar recommendations from guidelines in high-income countries .................................... 45 

Table 2.7: Beverage recommendations from guidelines in high-income countries ........................................... 47 

Table 2.8: Methods of dietary assessment .................................................................................................... 50 

Table 2.9: Tools available for the assessment of feeding behaviours in infants and children ............................. 64 

 

Chapter 3 

Table 3.1: Foods included and excluded in food group analyses ................................................................... 109 

Table 3.2: Consumption of breast milk and formula at least once and during both diet recalls days according to 

infant age .................................................................................................................................................. 110 

Table 3.3: Consumption of vegetables at least once and during both diet recalls days according to infant 

age…………………………………………………………………………………………………………………………………………………………………..112 

Table 3.4: Consumption of fruit at least once and during both diet recalls days according to infant age ......... 113 

Table 3.5: Consumption of grain foods at least once and during both diet recalls days according to infant age.

 ............................................................................................................................................................... .113 

Table 3.6: Consumption of milk and milk products at least once and during both diet recalls days according to 

infant age .................................................................................................................................................. 114 

Table 3.7: Consumption of meat and protein-rich foods at least once and during both diet recalls days according 

to infant age .............................................................................................................................................. 115 



 

 

 

X 

 

 

Table 3.8: Consumption of discretionary food at least once and during both diet recalls days according to infant 

age ........................................................................................................................................................... 116 

Table 3.9: Consumption of commercial infant food at least once and during both diet recalls days according to 

infant age .................................................................................................................................................. 117 

 

Chapter 4 

Table 4.1: Indicators developed from the Ministry of Health Infant Feeding Guidelines ................................. 136 

Table 4.2: Foods included and excluded in food group analyses ................................................................... 140 

Table 4.3: Demographic characteristics of infants and caregivers (n=625) ..................................................... 142 

Table 4.4: Summary of adherence to indicators developed from the Ministry of Health Infant Feeding Guidelines

 ................................................................................................................................................................ 143 

Table 4.5: Sociodemographic characteristics associated with adherence to breastfeeding recommendations

 .............................................................................................................................................................. ..145 

Table 4.6: Sociodemographic characteristics associated with adherence to solid food introduction 

recommendations ..................................................................................................................................... 147 

Table 4.7: Sociodemographic characteristics associated with adherence to food variety recommendations on 

both 24-hour recall days ............................................................................................................................ 150 

Table 4.8: Sociodemographic characteristics associated with adherence to the recommendation of not adding 

salt and sugar ............................................................................................................................................ 153 

Table 4.9: Sociodemographic characteristics associated with adherence to spoon-feeding recommendations

 ............................................................................................................................................................... .154 

 

Chapter 5 

Table 5.1: Feeding behaviour criteria for PediEAT total and subscale scores ................................................. 174 

Table 5.2: PediEAT norm reference scores for total PediEAT and subscales and participant mean score, with 

score ranges .............................................................................................................................................. 176 

Table 5.3: Sociodemographic characteristics associated with infants in the ‘no concern’ and ‘concern’ categories 

for total PediEAT, physiologic symptoms, problematic mealtime behaviours, and selective/restrictive feeding 

behaviours (n=554) ................................................................................................................................... 177 

Table 5.4: Food group consumption on both diet recall days associated with infants in the ‘no concern’ and 

‘concern’ categories for total PediEAT, physiologic symptoms, problematic mealtime behaviours, and 

selective/restrictive eating (n=554) ............................................................................................................ 180 

 

  



XI 

LIST OF FIGURES 

Chapter 3 

Figure 3.1: First Foods New Zealand study screening and consent pathway .................................................. 106 

Figure 3.2: Food group consumption at least once and during both diet recall days according to infant age ... 111 

Chapter 4 

Figure 4.1: (A) Exclusive breastfeeding prevalence (between birth and 4.9 months). (B) The percentage of infants 

receiving breast milk according to infant age. n=612. ...............................................................................144 

Figure 4.2: Infant age when solid foods were introduced (n=625) ................................................................. 146 

Chapter 5 

Figure 5.1: First Foods New Zealand study flow diagram of recruitment, consent, and those included in the final 

analysis ..................................................................................................................................................... 175 



 

 

 

XII 

 

 

LIST OF ABBREVIATIONS AND SYMBOLS 
 

Abbreviation or Symbol Definition 

AAP American Academy of Pediatrics 

AYCE About Your Child’s Eating 

BAMBI Brief Autism Mealtime Behaviour Inventory 
 

BLISS Baby-Led Introduction to Solids Study 

BLW Baby-led weaning 

BMI Body mass index 

BPFAS Behavioral Pediatrics Feeding Assessment Scale  

CDC Centers for Disease Control and Prevention 

CF Complementary feeding 

CFB Concerning feeding behaviours  

CEBI Children’s Eating Behaviour Inventory  

CEBQ Child Eating Behaviour Questionnaire  

CEDQ Children’s Eating Difficulties Questionnaire  

CIF Commercial infant food 

DONALD DOrtmund Nutritional and Anthropometric Longitudinally Designed Study 

DQIs Diet quality indices  

Dr Doctor  

EBF Exclusive breastfeeding 

e.g., For example 

ESPGHAN European Society for Paediatric Gastroenterology Hepatology and Nutrition 

Et al. and others  

FITS Feeding Infants and Toddlers Study 

FSANZ Food Standards Australia and New Zealand 

GUiNZ Growing up in New Zealand study 

HRC Health Research Council 



 

 

 

XIII 

 

 

Abbreviation or Symbol Definition 

ICFET International Complementary Feeding Evaluation Tool  

ICFI Infant and Young Child Feeding Indexes 

InFANT INfant Feeding, Active play and NuTrition Program  

MBQ Mealtime Behaviour Questionnaire  

MCHS Montreal Children’s Hospital Feeding Scale  

Meat and protein-rich foods Legumes, nut butters, eggs, fish, seafood and chicken, or lean red meat 

MoH Ministry of Health 

NZ New Zealand  

OzFITS The Australian Feeding Infants and Toddler Study  

PASSFP Paediatric Assessment Scale for Severe Feeding Problems 

PAHO Pan American Health Organization  

PubMed Medline Public Publisher  

RCT Randomised control trial  

SACN Scientific Advisory Committee on Nutrition 

SD Standard deviation  

STEP-CHILD Screening Tool of Feeding Problems Applied to Children 

TSF Traditional spoon-feeding 

UNICEF United Nations Children's Fund 

UK United Kingdom 

USA United States of America 

WHO World Health Organization  

YFNZ Young foods New Zealand  

  



 XIV 

LIST OF PAPERS AND CONFERENCE PRESENTATIONS 

Three papers, shown below, were written during the PhD candidature to meet the requirements of 

thesis by publication. Manuscripts are formatted for publication and will be submitted in the upcoming 

months. DRC 16 statements are presented in Appendix 2. Methods for the First Foods New Zealand 

Study have been published (Appendix 3), with the candidates input.  

• Paper I:

Contributions of Key Foods and Food Groups to the Dietary Intake of Infants in the First Foods

New Zealand Study

Paper II: Submitted to the Nutrients Journal 'Selected Papers from the 56th Annual 

Nutrition Society of New Zealand Conference' 

Adherence to Infant Feeding Guidelines in the First Foods New Zealand Study 

• Paper III:

Parent-reported Feeding Behaviours of New Zealand Infants and Associations with Demographic

Characteristics and Feeding Practices in the First Foods New Zealand Study

• Methods (Appendix 3)

Taylor RW, Conlon CA, Beck KL, von Hurst PR, Te Morenga LA, Daniels L, Haszard JJ, Meldrum AM,

McLean NH, Cox AM, Tukuafu L, Casale M, Brown KJ, Jones EA, Katiforis I, Rowan M, McArthur J,

Fleming EA, Wheeler BJ, Houghton LA, Diana A, Heath AM. Nutritional implications of baby-led

weaning and baby food pouches as novel methods of infant feeding: Protocol for an observational

study. JMIR Research Protocols, 10(4), e29048. https://doi.org/10.2196/29048

Conference presentations 

1. Nutrition Society conference: 1st and 2nd December 2022

‘Adherence to Breastfeeding and Complementary Feeding Guidelines within the First Foods New 

Zealand Study’.  

This research was extracted from paper II: Adherence to Infant Feeding Guidelines in the First Foods 

New Zealand Study. Awarded runner-up for best oral presentation.  



 

 

 

1 

 

 

CHAPTER 1 

AN INTRODUCTION TO THIS RESEARCH 
 

Starting with an introduction to infant feeding, this chapter provides a background and justification for 

the thesis. The introductory section is then followed by the thesis’s aims, objectives, hypotheses, thesis 

structure, and author contributions.   



 

 

 

2 

 

 

1.1. INTRODUCTION AND JUSTIFICATION FOR THE STUDY 
 

The provision of safe and nutritionally appropriate foods in early life sets a foundation for good health 

across an individual’s lifespan (Jang & Serra, 2014). However, unlike other life stages, food choices 

rapidly change during infancy, as infants transition from breast or formula milk as a sole food source to 

a diet consisting of a range of foods and beverages from the family diet (Birch et al., 2007; Grummer-

Strawn et al., 2008; Lioret et al., 2013). This can be a vulnerable phase of nutrition as an infant learns 

about new foods, tastes, and textures, developing food preferences that can last a lifetime (Berti & 

Agostoni, 2017; Birch & Doub, 2014; Nicklaus & Remy, 2013; Robinson & Fall, 2012). If poor food 

preferences and feeding behaviours are developed, individuals are more likely to make undesirable 

food choices in later life, increasing their risk of poor health. The diet during infancy, therefore, presents 

a window of opportunity to protect and promote good nutrition and healthy eating behaviours to 

support an individual’s immediate and long-term health. 

 

What is optimal infant nutrition? 

Until ‘around’ six months of age, an infant should receive all nutrition from breast milk (Ministry of 

Health, 2021a). Exclusive breastfeeding, or the provision of only breast milk for the first six months of 

life, has beneficial outcomes for both mothers and their offspring (Ministry of Health, 2021a). Infants 

who are breastfed have increased immune development and tolerance (Field, 2005), cognitive function 

(Anderson et al., 1999), and maternal bond (Horta & Victora, 2013). They also have a reduced risk of 

allergies (Robinson & Fall, 2012), gastrointestinal and respiratory infections (Duijts et al., 2009; Sankar 

et al., 2015), type two diabetes mellitus (Horta et al., 2015; Horta & Victora, 2013; Koletzko et al., 2019), 

and becoming overweight or obese (Arenz et al., 2004; Bartok & Ventura, 2009). Infants may also have 

an increased acceptance of new foods because of exposure to maternal dietary flavours in breast milk 

(Spahn et al., 2019; Stoody et al., 2019). Around the age of six months, breast milk is unable to provide 

adequate energy and nutrients, and solid foods should be introduced in addition to breast milk (Fewtrell 

et al., 2017). Breast milk, however, continues to be the greatest source of energy and total nutrients 

until one year of age (Ministry of Health, 2021a).  

The early introduction of solid foods, defined as before four months of age (Ministry of Health, 2021a), 

is associated with adverse health outcomes, including an increased risk of allergies (Fiocchi et al., 2006; 

Robinson & Fall, 2012), obesity (The Scientific Advisory Committee on Nutrition, 2018; Weng et al., 

2012), and gastrointestinal damage (Butte et al., 2004; Fewtrell et al., 2017). An infant’s renal system 



 

 

 

3 

 

 

is also not physiologically mature enough to handle solid foods (Butte et al., 2004). Around six months 

of age, an infant is developmentally ready to start complementary feeding (CF) and it is recommended 

that spoon-fed puréed foods are introduced (Fewtrell et al., 2017). The Ministry of Health (MoH) does 

not recommend using baby-led weaning (BLW), where an infant self-feeds finger foods from the start 

of CF, as further research is required to determine if it is a nutritionally safe and developmentally 

appropriate feeding method (Ministry of Health, 2021a). Instead, infants should be encouraged to 

participate in mealtimes and self-feed when developmentally appropriate (Ministry of Health, 2021a). 

This allows infants to learn how to eat, enjoy mealtimes, follow their natural hunger and fullness cues, 

and learn how new foods taste and smell.  

A variety of foods from each of the food groups should be introduced into the diet after CF has started, 

including vegetables; fruit; grain foods; milk and milk products; and legumes, nut butters, eggs, fish, 

seafood and chicken or lean red meat (referred to as meat and protein-rich foods in this thesis), 

progressing from a puréed texture to lumpy, mashed, and soft finger foods (Ministry of Health, 2021a). 

Each food group provides important nutrients for infant growth and development. However, not all 

foods are equal, and a variety of foods within each food group are required to meet daily nutrient 

requirements. Iron-rich foods are particularly important due to declining iron stores, and foods such as 

red meat, fish, poultry, and iron-fortified infant cereals, should be offered daily to meet infants' high 

iron requirements (EFSA Panel on Nutrition et al., 2019). Foods with different flavours, including 

naturally sweet, savoury, and bitter, should also be introduced to widen an infant’s taste preferences 

(Ministry of Health, 2021a) and reduce fussy eating tendencies (de Barse et al., 2017). Commercial 

infant foods (CIF) can be included in an infant’s diet if used in addition to home-cooked foods (Ministry 

of Health, 2021a). Pouches and mixed commercial products should be emptied into a bowl to allow 

infants to see, smell, and touch the food. CIFs are a convenient source of infant nutrition, however, if 

overused and not used in addition to home-cooked meals, they may reduce the variety of flavours and 

textures in an infant's diet (World Health Organization, 2021). For pouches, incorrect feeding through 

the nozzle instead of a spoon may also increase the risk of concerning feeding behaviours (CFB), 

overfeeding, and poor dental health (Theurich, 2018). Caregivers are also recommended to avoid 

feeding infants foods and beverages containing or with added salt and sugar. Adding salt or sugar 

changes the flavour of food and accustoms taste preferences for sweet and salty, which, when 

consumed in large amounts, are linked to heart disease and diabetes (Michaelsen, 2000; World Health 

Organization, 2015). Beverages such as juice, cordial, fruit drinks, flavoured milk, soft drinks, tea, and 

coffee should also be avoided as they do not enhance an infant’s nutrition and may promote undesired 

taste preferences (Ministry of Health, 2021a). Cow’s milk does not contain adequate nutrients 



 

 

 

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compared to breast and formula milk and should also be avoided as a beverage until one year of age 

(Ministry of Health, 2021a; World Health Organization, 2009).  

‘Normal’ feeding behaviours are not well defined and many infants experience difficulties when 

learning to eat (Pados et al., 2018). Responses such as gagging and refusal of new or unfamiliar foods 

are normal and typically resolve during the CF period. Behaviours are characterised as of concern when 

ongoing or when an infant will not eat enough despite the availability of appropriate foods (Kedesdy & 

Budd, 1998).  

 

Infant feeding guidelines in New Zealand  

The importance of infant feeding is recognised worldwide, as shown by the development of 

international and country-specific infant feeding recommendations. In New Zealand (NZ), dietary 

recommendations for infants and toddlers are guided by the recently updated ‘Healthy Eating 

Guidelines for New Zealand Babies and Toddlers (0-2 years)’ (Ministry of Health, 2021a). The 2021 

released guidelines include six evidence-based eating statements to support optimal feeding practices 

for breastfeeding, CF, diet variety, appropriate foods, appropriate beverages, and eating environments.   

 

What do we know about infant nutrition in New Zealand? 

Many countries have reasonably up-to-date evidence on infant food or nutrient intake (Eldridge et al., 

2019; Fox et al., 2004; Friel et al., 2010; Grummer-Strawn et al., 2008; Lennox et al., 2013; Lioret et al., 

2013; United Nations International Children's Emergency Fund, 2021; White et al., 2017). New Zealand, 

however, has little comparable evidence (Taylor et al., 2021), with no national health or nutrition 

surveys undertaken in infants. Instead, most evidence regarding infant nutrition comes from the 

Growing Up in NZ (GUiNZ) study. GUiNZ is a longitudinal nationally generalizable study of 6470 mother 

and infant dyads born between 2007 and 2010 (Morton et al., 2012). A wealth of information was 

collected on infant feeding practices and dietary intake, including the incidence of breastfeeding, 

adherence to the 2008 MoH infant feeding guidelines, sociodemographic characteristics associated 

with guideline adherence, and food consumption at nine months of age (Castro et al., 2021; Ferreira et 

al., 2023; Gontijo de Castro et al., 2018; Morton et al., 2012; Morton et al., 2014). In recent years, other 

NZ studies have focused on specific areas of infant nutrition, including the nutritional outcomes when 

following BLW (Cameron et al., 2012; Cameron et al., 2013; Fu et al., 2018; Morison et al., 2016; Taylor 

et al., 2021) and adherence to specific dietary guidelines (Ministry of Health, 2021b). These studies 



 

 

 

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provide some insight into the current nutrition and feeding practices of infants. However, many, 

excluding the national health survey, were unable to represent the ethnic diversity of the NZ 

population, reducing generalisability, with notable associations between infant feeding practices and 

sociodemographic characteristics noted in GUiNZ (Morton et al., 2012). 

 

Various methods are available to assess feeding behaviours, including questionnaires and coding tools. 

Parent-reported questionnaires are minimally burdensome, affordable, highly repeatable, suitable for 

tracking feeding behaviours over time, and appropriate for research (Thoyre et al., 2014). The 

Paediatric Eating Assessment Tool (PediEAT) is a validated parent-reported questionnaire that 

measures CFB. Unlike most other questionnaires, PediEAT uses subscales to describe the type of CFB, 

including physiologic symptoms, problematic mealtime behaviours, selective/restrictive eating, and 

oral processing concerns (Thoyre et al., 2014). Parent concerns about infant feeding behaviours are 

commonly reported in high-income countries (Benjasuwantep et al., 2013; Goday et al., 2019). The 

prevalence of CFB in NZ infants is currently unknown, although other high-income countries have 

reported that at least 25% of typically developing children (Benjasuwantep et al., 2013; Goday et al., 

2019) and 80% of children with developmental disabilities or diagnosed medical conditions (Gal et al., 

2011; Goday et al., 2019) have CFB. Behaviours have also been associated with sociodemographic 

characteristics, with a higher prevalence of CFB in older and male children (Antoniou et al., 2016; Brown 

et al., 2018; Chilman et al., 2021; Tharner et al., 2014; Wardle et al., 2001), those living in high 

deprivation, and caregivers with low household income or education level (Emmett et al., 2018; Qiu & 

Hou, 2020; Tharner et al., 2015). Typically children with CFB are less likely to consume fruits and 

vegetables (Carruth et al., 1998; Perry et al., 2015; Switkowski et al., 2020). Previously breastfeeding 

has been associated with improved food acceptance in infants (Hausner et al., 2009; Mennella et al., 

2017; Mennella et al., 2001; Sullivan & Birch, 1994) and reduced incidence of fussy eating tendencies 

behaviours in children (Cooke et al., 2004; Galloway et al., 2003). This is thought to be the result of 

exposure to a variety of flavours from the maternal diet.  

During the last decade, there have been significant changes in how infants are fed, with increasing 

availability of CIF (Katiforis et al., 2021; Padarath et al., 2020) and trends surrounding BLW (Brown et 

al., 2017; Cameron et al., 2013). In 2020, 266 CIF foods from 19 brands were found in two major NZ 

supermarket chains (Foodstuffs and Woolworths) (Katiforis et al., 2021), and a recent report showed a 

27% increase in products available in the baby food sector between 2010 and 2016 in NZ (GlobalData, 

2016). The use of CIF has likely changed since GUiNZ. However, despite the increasing availability of 



 

 

 

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CIF, there is limited evidence available to determine the use of CIF, feeding methods used (e.g., spoon-

feeding or direct consumption from products), and the influence products have on nutrient intake in 

NZ (Katiforis et al., 2021; Rowan et al., 2022). However, BLW seems to be growing in popularity (Brown 

et al., 2017; Cameron et al., 2013) despite not being recommended by the MoH (Ministry of Health, 

2021a). Our knowledge surrounding infant feeding in NZ is therefore limited, and with the emergence 

of BLW (Brown et al., 2017; Cameron et al., 2013) and the increasing availability of CIF (Katiforis et al., 

2021; Padarath et al., 2020), there are likely to be significant changes in what and how infants are fed.   

 

Introducing the First Foods NZ study  

First Foods New Zealand (FFNZ) is a Health Research Council (HRC) funded observational study of 625 

Dunedin and Auckland infants aged 7.0 to 10.0 months. FFNZ aims to provide up-to-date insight into 

the changes that occur as an infant progresses from a diet consisting of 100% milk to one that resembles 

family meals. This information will allow a greater understanding of what NZ whānau (families) are 

feeding their infants and their feeding methods. Key outcomes of FFNZ include infant iron status, 

growth, food and nutrient intake, breastfeeding incidence, eating and feeding behaviours, dental 

health, oral motor skills, and choking risk of New Zealand infants in general and those using pouches or 

BLW. This thesis will provide information on infant food and food group consumption, adherence to 

key MoH infant feeding guidelines, and parent-reported feeding behaviours in NZ infants between 7.0 

and 10.0 months of age. This information will provide the MoH, health professionals, and NZ health and 

wellbeing organisations such as Plunket with up-to-date evidence on infant nutrition in NZ.  

 

 

 

  



 

 

 

7 

 

 

1.2. THESIS AIMS 
 

The overall aims of this thesis were to investigate the following in NZ infants between 7.0 and 10.0 
months of age: 

1) Contributions that key foods and food groups make to the dietary intake of NZ infants, 

2) Adherence of infants to key dietary indicators based on the Ministry of Health’s Healthy Eating 

Guidelines for New Zealand Babies and Toddlers (0–2 years old), 

3) Describe parent-reported feeding behaviours of NZ infants and associations with demographic 

characteristics and feeding practices.  

1.3. THESIS OBJECTIVES 
 

1. Explore the contributions that key foods and food groups make to the dietary intake of NZ infants 

between 7.0 and 10.0 months of age. 

 
1.1. Describe the food and food groups contributing to the dietary intake of NZ infants, 

1.2. Describe differences in food and food group intake in NZ infants between 7.0 to 10.0 months 

of age, 

1.3. Describe the contribution of commercial infant foods to the dietary intake of NZ infants. 

 

2. Investigate adherence to key dietary indicators of NZ infants between 7.0 and 10.0 months of age, 

as guided by the Ministry of Health’s Healthy Eating Guidelines for New Zealand Babies and 

Toddlers (0–2 years old). 

 
2.1. Describe adherence to exclusive and current breastfeeding guidelines, 

2.2. Describe adherence to complementary feeding guidelines, including the age of solid 

introduction, appropriate foods introduced, appropriate textures, and appropriate feeding 

styles, 

2.3. Describe adherence to food variety guidelines, including the consumption of vegetables, fruit, 

grain foods, milk and milk products, and meat and protein-rich foods (legumes, nut butters, 

eggs, fish, seafood, chicken, or lean red meat), 

2.4. Describe adherence to appropriate food and beverage guidelines, including the offering of 

appropriate drinks and avoiding the addition of salt and sugar, 

2.5. Describe adherence to self-feeding guidelines, 

2.6. Determine sociodemographic characteristics associated with guideline adherence. 



 

 

 

8 

 

 

 

3. Describe parent-reported feeding behaviours of NZ infants between 7.0 and 10.0 months of age 

and associations with demographic characteristics and feeding practices.  

3.1. Describe parent-reported feeding behaviours of NZ infants, according to the Paediatric Eating 

Assessment Tool (PediEAT) total and subscale scores, 

3.2. Describe associations between parent-reported feeding behaviours and infant and parent 

demographic characteristics,  

3.3. Describe associations between parent-reported feeding behaviours and infant feeding 

practices (current breastfeeding and food group consumption). 

 

1.4. STUDY HYPOTHESES 
 

1. Key food contributors within the five food groups will differ between infants of different ages. Older 

infants will be more likely to meet the MoH food group recommendations.  

2. Adherence to key indicators will vary between infants with different demographic characteristics, 

including maternal age, education, parity and employment status, early child education centre 

attendance, the number of children in the household, and deprivation.  

3. Differences in parent-reported feeding behaviours according to infant and parent demographics 

and feeding practices will be observed. Infants with concerning parent-reported feeding behaviours 

will be less likely than infants without to consume the MoH food groups (vegetables, fruit, grain 

foods, milk and milk products, and meat and protein-rich foods) and more likely to consume CIF. 

 

1.5. THESIS STRUCTURE 
 

This thesis is divided into six chapters. Chapter one is an introductory chapter, providing a background 

and justification of the study, aims, objectives, hypotheses, and author contributions. A narrative 

review in chapter two outlines the current NZ and international recommendations for feeding infants 

and critically reviews the current evidence on infant nutrition and dietary intake, adherence to key 

dietary indicators, and dietary behaviours. Chapters three, four, and five present research findings, 

answering the study's three aims. These chapters are presented as manuscripts for publication with the 

inclusion of abstracts, introductions, methods, results, discussion, references and links to appendices 



 

 

 

9 

 

 

as relevant to the chapter. The final chapter, chapter six, provides a discussion of the key study findings, 

research outcomes, study limitations, and directions for future research. The appendices include 

relevant documents to support an understanding of the study, including recruitment resources, the 

published FFNZ protocol paper, participant information sheets, relevant standard operating procedures 

(SOPs), resources used during data collection, copies of the main and final questionnaires, and the 

candidates’ abstract that was published in the Nutrition Society of NZ conference proceedings. 

 

1.6. RESEARCHER CONTRIBUTIONS 
 

This thesis uses data from the First Foods NZ study (FFNZ). The candidate played a significant role in all 

aspects of the study, including writing and reviewing study protocols, recruitment, data collection (both 

Auckland and Dunedin), data quality checking, data management and cleaning, development of the 

FFNZ food coding system, food and food group coding, and data analysis. The candidate was involved 

in all aspects of FFNZ data collection, including the collection of infant anthropometry, infant dental 

images, and saliva samples from breastfeeding mothers and infants. This thesis does not discuss these 

outcomes; they are part of the wider FFNZ study aims. The candidate also collected data for an 

associated study: Young Foods New Zealand (YFNZ), as cohorts overlapped when multiple children 

resided in a home. An overview of contributions made by the candidate are available in Table 1.1. 

Several individuals were involved in FFNZ and contributed to this research, as discussed below: 

Professor Anne-Louise Heath and Professor Rachael Taylor were the study’s primary investigators and 

led the research. They oversaw the overall FFNZ study, designed and developed the study, applied for 

research funding and ethics approval, developed the study protocols, assisted in protocol training, and 

mentored and allocated student roles.  

Professor Cathryn Conlon, Professor Pamela von Hurst, Associate Professor Kathryn Beck, Associate 

Professor Lisa Te Morenga, and Associate Professor Jill Haszard were FFNZ co-investigators. They were 

involved in the design and development of the study, research funding applications, and obtaining 

ethical approval. Additionally, they reviewed study protocols, questionnaires and data collection 

strategies. Professor Cathryn Conlon (main), Professor Pamela von Hurst (co), and Associate Professor 

Kathryn Beck (co) were the candidate’s supervisors. They mentored the candidate, provided academic 

support for the development and design of this thesis, reviewed and revised each thesis chapter, 

assisted in the dissemination of the results, and approved the thesis for submission.  



 

 

 

10 

 

 

Lisa Daniels (postdoctoral fellow) was involved in the study conceptualisation, writing, and review of 

protocols. Associate Professor Lisa Te Morenga provided cultural advice and ensured that FFNZ 

researchers and publications were culturally safe and met the needs of the NZ population. Associate 

Professor Jillian Haszard provided statistical support for data analysis and the dissemination of the study 

results. She was involved in the development of student aims and objectives, statistical method design, 

data cleaning, statistical analysis, and dissemination of results.  

Jenny McArthur and Rebecca Paul assisted in recruitment, participant bookings, and data collection in 

Dunedin and Auckland, respectively. They worked closely with FFNZ and YFNZ PhD students Maria 

Casale, Emily Jones, Rio Jupiterwala, Neve McLean, Alice Cox, Ioanna Katiforis, Lesieli Tukuafu, and 

Master’s students Madeline Rowan, Madeline Gash, Bailey Bruckner, and Annabelle Malone, who 

assisted in the development and reviewing of study protocols, protocol training, recruitment, data 

collection, data entry, data cleaning, and dissemination of results in their specific areas of research. 

Additional support for data collection was received from research assistants Andrea Wei, Emily 

Shoesmith, Darrian Holten, Ella Brouwer, Marsha Piddington, and Shay Whickham. 

Elizabeth Fleming, Elizabeth Jones, and Ioanna Katiforis led FoodWorks data entry, with the candidate 

conducting quality checking of recalls. The candidate and Ioanna Katiforis then developed the FFNZ 

food coding system under the supervision of Elizabeth Fleming and Professor Anne-Louise Heath. 

Ioanna Katiforis and the candidate were responsible for coding foods consumed during the diet recalls.  

 

 



 

 

 

11 

 

 

Table 1.1: Candidate research contribution 

Stage  Task Contribution  

Study development Study protocols Assisted in the development of the recruitment, food recall, photo transfer, final questionnaire, and frequently asked question protocols. Reviewed all 
study protocols and advised revisions.  

Study questionnaires  Assisted in the development of the main questionnaire. Reviewed the main and final questionnaires. 

Participant forms Assisted in the development of the participant information sheet, consent form, and diet recall forms.  

Training Engaged in student training for all areas of FFNZ data collection, including peer observations of 24-hour diet recalls. 

Adherence indicator Developed the indicators presented in chapter three (Adherence to infant feeding guidelines) based on the 2021 Ministry of Health infant feeding 
guidelines and available data from the study to assess adherence to the infant feeding guidelines. 

Food coding system  Developed FFNZ’s food group and ingredient coding system and trained other team members to use the standard operating procedures and 
codebooks. 

Flow chart  Developed the flow charts for Auckland and Dunedin to support researchers. Charts included a study timeline, equipment required at each visit, and 
visit objectives. Charts were used by researchers to prepare for appointments and ensure appropriate equipment was available during appointments. 

Recruitment  Assisted in the development and design of advertisements, posters, media content, and the FFNZ website and Facebook account. 

Assisted in the promotion of FFNZ and developed targeted recruitment strategies for Māori and Pacific participants. 

Assisted in screening new participants and scheduling appointments. 

Data collection Participant visits  Collected data in both Auckland and Dunedin. Conducted onsite, home, and online appointments in both locations. 

Tracking documents Designed and monitored documents for tracking new and current participants for Auckland and Otago. This ensured that all researchers understood 
what the participant had completed and were yet to complete. Follow-up contacts and notes were added when required (e.g. requested diet recall 
images on 21 April). 

Ethnicity targets Designed Red-Cap reports to track ethnicity numbers. This aided the wider team to monitor study targets during data collection. 

Student + research 
assistant support  

Supported new students and research assistants during study visits and administration. 



 

 

 

12 

 

 

Stage  Task Contribution  

Data management FoodWorks quality 
check 

Assisted in FoodWorks data quality checking – checking 100% of formula entries and 45% of total recalls. Engaged in weekly team meetings to discuss 
data errors for FFNZ and YFNZ. 

Food groupings  Individually coded foods (n=12,628) into food groups and ingredients after discussions with the supervisory team. Supported the YFNZ team to 
complete ingredient and food group coding (n=19,577)  

Engaged in weekly meetings to discuss problematic foods and coding requirements.  

Data analysis Worked alongside the study statistician to review data quality and results presented in this thesis. All data analysis strategies were initially developed 
by the candidate and confirmed after consultation with the study statistician. 

Analysed all food and food group data presented in manuscript one and the food group, salt, and sugar data presented in manuscript two.  



 

 

 

13 

 

 

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CHAPTER 2 

A REVIEW OF THE CURRENT LITERATURE 
 

THIS CHAPTER REVIEWS THE CURRENT LITERATURE ON INFANT DIETARY INTAKE, ADHERENCE TO INFANT FEEDING 

GUIDELINES, AND FEEDING BEHAVIOURS IN NEW ZEALAND AND HIGH-INCOME COUNTRIES. MULTIPLE SEARCH 

TERMS DERIVED FROM THE STUDY OBJECTIVES WERE USED BETWEEN JANUARY 2020 AND APRIL 2023.  

APPENDIX 1 PROVIDES FURTHER INFORMATION ON THE SEARCH STRATEGY.  

  



 

 

 

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2.1.        INFANT FEEDING GUIDELINES  
 

Nutrition plays a crucial role in the first years of life, directly influencing infant growth (Dewey, 2001), 

development (Dewey, 2003; Ministry of Health, 2021a), and lifelong dietary habits (Matthews et al., 

2019; Reidy et al., 2017; Schwartz et al., 2011; Young & Krebs, 2013). Inadequate nutrition during early 

life leads to stunting, poor cognitive development, and increased morbidity (Black et al., 2008), with 

the highest prevalence of undernutrition worldwide occurring during the complementary feeding (CF) 

period (Victora et al., 2010). Conversely, overfeeding has been associated with excessive weight gain 

and metabolic programming, influencing the development of non-communicable diseases (Hanson & 

Gluckman, 2011; Singhal, 2016; Wu & Chen, 2009). Due to the negative implications of under and 

overfeeding, the importance of optimal dietary choices during infancy is well known (World Health 

Organization, 2015b). To support optimal practices, infant feeding guidelines have been developed 

worldwide. 

 

2.1.1. A GLIMPSE INTO THE HISTORY OF INFANT NUTRITION 

 

Feeding practices have evolved significantly in the past 250 years as knowledge surrounding infant 

feeding has increased (Jones, 2016). From early times, the importance of breastfeeding was recognised 

for infant growth and development. However, not all women were able or wanted to breastfeed 

(Radbill, 1981; Stevens et al., 2009; Wickes, 1953a). This led to many women using a wet nurse, ‘a 

woman who breastfeeds another's child’ before the introduction of early infant formulas (Stevens et 

al., 2009). Wet nursing provided an alternative means of feeding and became popular in the early 18th 

century for women of higher social class (Wickes, 1953b). However, when evidence emerged for the 

maternal benefits of breastfeeding, a shift was observed, with working-class women becoming the 

leading employers of wet nurses. This was common until 1900 when milk alternatives (animal milks) 

became popular (Minchin, 2018; Osborn, 1979).  

Early feeding practices were associated with high morbidity and mortality rates because of poor 

hygiene and sterilisation practices, the offering of low-nutrient or inappropriate foods, and sudden 

weaning from breast milk (Davies & O’Hare, 2004; Katzenberg et al., 1996; Weinberg, 1993). 

Recommendations for introducing solid foods were more ambiguous during early history. Like today, 

different recommendations were found in different parts of the world (Minchin, 2018). Until the 

Renaissance period, offering solid foods (such as meat, fruit, and vegetables) typically occurred at two 



 

 

 

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or three years of age, after the final milk tooth had erupted (Forsyth, 1911; Levin, 1959). However, in 

parts of the world, thin gruels, such as pap (bread soaked in water, milk, wine or beer) and panada 

(cereals cooked in meat or vegetable broth), were cautiously added around six months of age (Forsyth, 

1911; Levin, 1959; Obladen, 2014). By the 15th and 16th centuries, reports appear that gruels were 

frequently fed from birth, often in the replacement of breast milk (Forsyth, 1911; Levin, 1959; Obladen, 

2014). When gruels were of a thicker consistency, pre-mastication, where a parent or caregiver chewed 

food into a suitable texture before feeding to an infant, was common practice (Pelto et al., 2010).  

Until the end of the nineteenth century, animal milk was the most common source of artificial feeding 

(Radbill, 1981). Pap and panada were also commonly added to bottles/devices to support infants with 

faltering growth (Forsyth, 1911; Radbill, 1981; Wickes, 1953b). However, poor sanitisation practices 

resulted in a high mortality rate. Infant formulas started to appear in the 18th century, with the first 

powdered form produced and marketed in 1865 (Radbill, 1981). By 1883, 27 branded powdered infant 

food products were available in the United States of America (USA) (Fomon, 2001). Initially, these were 

poor sources of nutrition, however, over time, protein, vitamins, and minerals were added alongside 

recommendations for appropriate sanitation techniques (Fomon, 2001). Between 1940 and 1970, a 

steady decline in breastfeeding was observed, with many physicians and mothers promoting formula 

as a safe substitute for breastfeeding (Minchin, 2018). Because of this decline, regulations for the 

marketing of formula were put in place in the 1970s to support women who were not able to breastfeed 

(Fomon, 2001).  

Following the development of early infant formula, recommendations for introducing solid foods 

changed again, with solid food considered unsuitable before a year of age. However, many parents 

continued to offer gruels by six months of age. Commercial infant foods (CIF), including jars of apple 

purée, also appeared during this century and were highly recommended by paediatricians for those 

over one year of age (Radbill, 1981). In the late 19th and early 20th centuries, it was rare to offer solid 

foods before one year of age, following fears that this would harm ‘the delicate child’ (Fomon, 2001). 

However, the discovery of vitamins in 1912 (Funk, 1912) promoted change. By 1920, it was 

recommended that meat and liver were introduced during the first two weeks of life, followed by 

cereals, vegetables, and fruit (including juice), forming a mixed diet by one year of age (Jundell, 1923). 

The latter was a significant factor in minimising scurvy (Apple, 1987; McCollum, 1957). Rickets were 

also problematic at this time, and supplementation with cod-liver oil after birth became common 

practice in the USA (Apple, 1987; Holt, 1963).  

 



 

 

 

25 

 

 

By the 1950s, knowledge surrounding the physiological process of chewing and swallowing was 

developing, and guidelines started referencing the importance of an infant being able to transfer food 

from the front of the tongue to the pharynx for safe eating (Bakwin & Bakwin, 1953). Infants were 

subsequently offered an array of foods, including fruit (commonly banana), chocolate, juice, ice cream, 

custard, and vegetables from a young age (American Academy of Pediatrics Committee, 1958; Levin, 

1959). In 1958 the American Academy of Pediatrics (AAP) released its first report on infant feeding, 

acknowledging that the developmental maturity of the gut, growth, and activity level of an infant were 

better indicators than age to determine if the introduction of solid foods was appropriate (American 

Academy of Pediatrics Committee, 1958). However, the report suggested that these indicators were 

typically present between three and four months of age. Since then, recommendations for the 

appropriate age to start solid foods have varied between eight weeks (1960s) (Harris & Chan, 1969; 

Jones et al., 1964), four months (1970s) (Challacombe, 1983; Fomon, 1975; Fomon & Anderson, 1972), 

and six to nine months (1990s) (Grimshaw et al., 2009); significantly influenced by a greater 

understanding of the development of allergies and coeliac disease (Koplin & Allen, 2013).  

 

Infant feeding in New Zealand  

New Zealand (NZ) shares a similar history, following a slightly later timeline (Apple, 1994). A key 

difference in NZ’s history was the inception of Plunket in 1907 by Sir Frederick Truby King (Bryder, 

2008). Plunket, named after Lady Victoria Plunket, wife of the NZ governor at the time, aimed to 

promote maternal and infant health by providing care from trained nurses (Bryder, 2001). A decade 

after its initiation, NZ had the lowest infant mortality rate in the world (Bryder, 2017). A vital component 

of this success was the promotion of breastfeeding (Bryder, 2001), the opening of infant hospitals 

(Ryan, 1997), and recommendations of spoon-feeding solid foods rather than adding them to bottles 

(Jones, 2016; Ryan, 1997). Truby King recommended breastfeeding four-hourly between 6am-10pm, 

avoiding night feeding (Jones, 2016; Ryan, 1997). Additionally, infants were to receive fruit juice from 

two to three weeks of age and cod liver oil from one month. In the cases of failure to thrive, formula 

was supported. The introduction of solid foods was recommended to start no later than nine months 

of age, introducing food groups one at a time (Jones, 2016; Ryan, 1997).  

Over time, the appropriate age for CF changed with differing opinions of medical professionals and 

women (Minchin, 2018). Post-war, the cessation of breastfeeding was reported to occur earlier, with 

40% of infants being weaned by 12 weeks of age (Bryder, 2005). Women returning to work was 

considered a factor in this shift, with married women accounting for 42% of working women in 1966 



 

 

 

26 

 

 

(Nolan, 2000). The prevalence of breastfeeding, however, improved as knowledge developed for the 

benefits of breastfeeding (Bryder, 2005). CF practices also improved as scientific evidence grew for 

feeding infants (Deem & Fitzgibbon, 1964).  

 

New feeding trends  

In recent years, how infants are fed has changed with the emergence of a new feeding method known 

as baby-led weaning (BLW). Gill Rapley first described BLW in 2005 (Rapley & Murkett, 2008) and has 

increased in popularity globally (Brown et al., 2017; Cameron et al., 2013) following the 2002 World 

Health Organization (WHO) guideline change, advising that CF should start at six months instead of the 

previously advised four months (World Health Organization, 2002). Given the significant developmental 

changes that occur between four and six months, advocates for BLW have suggested that an infant 

does not need purées or to be spoon-fed (Rapley & Murkett, 2008). Instead, they are physiologically 

able to self-feed family food. BLW is not currently recommended in NZ (Ministry of Health, 2021a). 

However, given its increase in popularity, several studies have investigated the potential benefits of 

better energy self-regulation and improved motor skills, and risks including choking, inadequate 

nutrient and energy intake, suboptimal iron status, and diet quality, with inconclusive results (Brown et 

al., 2017; Cameron et al., 2012; D’Auria et al., 2018; Fewtrell et al., 2017; Rapley, 2011; Rapley & 

Murkett, 2008; Townsend & Pitchford, 2012). It is not currently known how pervasive BLW is in NZ, 

although a recent NZ study (n=876) suggested that more than half of families have tried it, with 

approximately 30% following BLW regularly (Fu et al., 2018). This is higher than those observed in 2013, 

with 8% of caregivers (n=199) meeting strict BLW criteria (Cameron et al., 2013), however, lower than 

observations in the United Kingdom (UK) (30 to 60%) (Brown, 2016; Rowan et al., 2019), Ireland (49%) 

(Mezynska et al., 2020), and Australia (46%) (Swanepoel et al., 2020). Due to the nutritional risks of 

BLW, increased popularity, and widespread online presence (about 13,700,000 results; Google 28 April 

2023), further research is required to determine the incidence and health risks of BLW so that health 

professionals and policymakers can provide whānau (families) with evidence-based advice on how to 

feed their infants safely.  

The availability of CIF has also changed in recent years, with a notable increase in products marketed 

towards infants in NZ (Katiforis et al., 2021; Padarath et al., 2020). In 2021, a study found 266 CIF 

available in two major NZ supermarket chains (Foodstuffs and Woolworths) (Katiforis et al., 2021). This 

was notably higher than those previously identified (Padarath et al., 2020). CIF are now available in 

various forms, including single-use food pouches (with and without plastic nozzles), jars, cans, 



 

 

 

27 

 

 

microwavable bowls, cereals, crackers, bars, biscuits, rusks, and extruded snacks. This is different to the 

glass jars of puréed fruit and vegetables seen in the past. Concern has been expressed about the 

nutritional content of CIFs, including the total energy, sugar, and iron contained in many products (Pask, 

2020; Sundborn et al., 2017). The use of plastic nozzles to feed directly from pouches is also concerning, 

with the recent Australian Feeding Infants and Toddlers Study (OzFITS) (n=598) reporting that half of 

those who consumed a pouch (n=299) sucked the contents directly through the nozzle (Netting, 

Moumin, Makrides et al., 2022). In NZ, the utilisation of CIF and use of nozzles is unknown (Taylor et 

al., 2021).  

 

2.1.2. THE NEW ZEALAND MINISTRY OF HEALTH INFANT FEEDING GUIDELINES  

 

The NZ ‘Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2)’ (Ministry of Health, 

2008) were originally developed in 2008 and aimed to provide caregivers and health professionals with 

evidence-based recommendations specific to NZ. The series was recently transitioned and updated to 

include evidence-based recommendations for nutrition and physical activity, following an independent 

evaluation of the Ministry of Health’s (MoH) Food and Nutrition Guidelines in 2011 (Ministry of Health, 

2020a). The 2021 infant guidelines, ‘Healthy Eating Guidelines for New Zealand Babies and Toddlers (0–

2 years old)’, were written by infant nutrition experts with the support of a maternal, infant, and toddler 

technical advisory group (