An Investigation of Infant Feeding Practices: The Relationship Between Matemal and Wmt Factors

and the Introduction of Soiid Foods.

by

Beth Sara Kwavnick

Submitted in partial fulfilment of the requirements for the degree of Master of Science

in Community Health and Epidemiology

Dalhousie University Halifax, Nova Scotia

June, 1998

O Copyright by Beth Sara Kwavnick, 1998

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Table of contents

........................................................... Listoftables iv

......................................... 1 . Background and literature review 1 ........................................ 1.1 Introduction and rationale 1

1.2 Trends in solids introduction .................................... - 3 1.3 Trends and infant feeding practices in Canada ........................ 3 1.4 Pediatric guidelines in developed countnes .......................... 5

.............................. 1.5 Canadian Pediatric Society guidelines 5 ......................... 1.6 Basis upon which guidelines are developed - 6

............................ 1.7 Influentid factors in solids introduction - 7 1.8 Advantages and disadvantages of the early introduction of solid foods .... - 8

......................... 1.9 Rationale for variables included in analyses Il

2 . Methods ........................................................... 16 ............................................ 2.1 Research objectives 16

....................... 2.2 S tudy design, data collection and venfication 16 ................................................... 2.3 Definitions 18

............................................... 2.4 uitemdvalidi ty 18 ............................ 2.5 Ethics review and confidentiality issues 19

......................................... 2.6 Sample size and power 19 ................................................ 2.7 Data analysis -20

.......................................... 2.7.1 Descriptive -20 ............................................ 2.7.2 Andflical 22

2.7.2.1 Decision d e s for inclusion of variables ......................... in multivariable models - 2 2

3 . Results ............................................................. 28 ............................................... 3.1 Response rate -28

.............................................. 3.2 Extemalvalidity 28 ................................ 3.3 Description of survey populations 30

3.4 Relationship between age of solid food introduction and matemal ......................................... andinfantvariables 36

3.4.1 1988 survey .......................................... 37 3.4.2 1992survey .......................................... 39

......................................... 3.4.3 1996 survey -40

.......................................................... 4 . Discussion 81 4.1 Interpretation of results in view of CPS guidelines .................. - 81 4.2 Cornparison of the descriptive results with the Canadian literature ...... -84 4.3 Cornparison of the analytical results with the international literature ..... 85 4.4 Socio-econornic variables and early solid food introduction:

..................................... What is the comection? -88

..................................... 4.4.1 Education and age -88 ........................................ 4.4.2 Social support -88

........................... 4.4.3 Environmental tobacco smoke -89 .................................. 4.5 Study strengths and limitations -90

4.6 Low SES, lack of breastfeeding and early solid food introduction: What are the potential reasons for this relatiooship? ................ 94

4.7 The successful promotion of breastfeeding ........................ -99 .................................. 4.8 Summary of recommendations 100

................................................. 4.9 Conclusions 102

Listofappendices ..................................................... 104

References ........................................................... 170

List of tables

Table 1 - Description of questionnaire variables ............................. .25

Table 2 - The number and percentage of completed surveys, by year of shidy. ...... - 4 7

Table 3 - Percent distribution of ail women aged 15 to 44 years by marital status, who had at least one child at the t h e of the 1991 Census of Canada (June 4, 1991) (first three columns) and the percent distribution of d l women in the 1988, 1992 and 1996 Ottawa-Carleton surveys by marital status. ........................... .48

Table 4 - Percent distribution of al1 women by age who had at least one child at the time of the 1 99 1 Census of Canada (June 4, 199 1) (fïrst three columns) and the percent distribution of al1 women in the 1988,1992 and 1996 Ottawa-Carleton surveys by

............................................................. age 49

Table 5 - Percent distribution of ever-married women aged 15 to 44 years by highest level of education, who had at least one child at the tirne of the 1991 Census of Canada (June 4, 199 1) ( h t column) and the percent distribution of ail women in the 1988, 1992 and 1996 Ottawa-Carleton by highest level of education. ........... .50

Table 6 - Percent distribution of infants according to the type of miik feeding at birth, ................................................. byyearofstudy. 51

Table 7 - The mean and median age at &t solid food, by year of study. ........... .52

Table 8 - Age of infant at solid food introduction, by year of study. .............. .53

Table 9 - Percent distribution of infants by age at solid food introduction, according to . . . . . . . . . . . . . . . . . . . . . the type of mik feeding at birth, by year of study. -54

Table 10a - Percentage of infants introduced to solid foods before 4 months of age . . . . . . . . . . . . . . . . . . . . . . . . . according to their rnilk feeding method at birth. 55

Table lob - Percentage of infants introduced to solid foods before 4 months of age .............. according to their milk feeding method at six months of age. -56

Table 11 - Percent distribution of infants by age at solid food introduction according to the . . . . . . . . . . . . . . . . . . . type of milk feeding at 6 months, for the 1988 cohort. . 5 7

Table 12 - Percent distribution of infants by age at solid food introduction according to the type of miik feeding at 6 months, for the 1992 cohort. ................... .58

Table 13 - Percent distribution of infânts by age at solid food introduction according to the ................... type of miik feeding at 6 months, for the 1996 cohort. - 5 9

.. Table 14 - Profile of babies introduced to cow's miik by 6 rnonths, in 1992 cohort. . 6 0

Table 15 - Profile of babies introduced to cow's milk by 6 months, in 1996 cohort. .. - 6 0

Table 16 - Percent distribution of infants according to the type of mik fed at birth and at six months, by year of study (1988 n=370; 1992 n=326; 1996 n=324). .......... 64

Table 17 - Percent distribution of infants according to the type of food they were first given, by year of study. ........................................... .65

Table 18 - Percent distribution of infants according to age and type of h t solid food introduced, by year of study. ....................................... - 6 6

Table 19 - Percent distribution of infants according to the different types of food they have been fed by 6 months of age, by rnilk feeding method at birth and 6 months, for the 1996 cohort. Total sample size = 338. ............................... - 6 7

Table 20 - Percent distribution of infants by age according to the different types of food they have been fed by six months of age, in the 1996 cohort. Total sarnple size = 338.

Table 21 - Matemal and mik feeding characteristics in relation to the introduction of solid foods at 4 and 24 rnonths of age, by year of study ( X tests). . . . . . . . . . . . . . 6 9

Table 22 - Smoking and ETS in relation to the introduction of solid foods 4 and 24 months of age, by year of sudy ( X tests). ................................ - 7 1

Table 23 - A cornparison of mother's (n=363) and father's (n= 10) responses, forthe1988cohort. ............................................... 72

Table 24 - Matemal and infant characteristics associated with the likelihood of solids being .......................... introduced before 4 months, by year of study. . 7 3

Table 25 - Selected characteristics associated with the introduction of solid foods before 4 ........... months after adjustment for other variables for the 1988 cohort. .75

Table 26 - Selected characteristics associated with the introduction of solid foods before 4 months after adjustment for other variables for the 1992 C O ~ O ~ . ........... - 7 6

Table 27 - Selected characteristics associated with the introduction of solid foods before 4 ........... rnonths after adjustment for other variables for the 1996 C O ~ O ~ . . 7 7

vii

Table 28 - Materna1 and infant characteristics, and the assocation with the likelihood of solids being introduced before 4 months, by year of study. . . . . . . . . . . . . . . . -79

Abstract

Canadian studies indicate that the Canadian Pediatric Society (CP S) guidelines

regardhg the introduction of solid foods are not generaüy followed. The CPS recommends

that solid foods be introduced between four to six months of age, depending on the

developmental readiness of the infant. Parents of three cohorts of six rnonth old infants h m

Ottawa-Carleton, Ontario (n=373, 1988; n=330, 1992; n=338, 1996) were interviewed.

These data were used to descnbe the iofant's age at introduction of first food and tc

determine the relationship betweem socio-demographic charactenstics and breastfeeding

practices of infant's mothers, and the introduction of solid foods before four months of age.

Approximately 20 percent of the infants in the sample were introduced to solid foods before

four months of age; cereal was the predomlliant food given. This shidy is the k t in Canada

to examine the effect of socio-demographic factors and breastfeeding history on solid food

introduction. Using logistic regression analysis, it was detennined that rnothers tended to

introduce solid foods before four months of age if they did not breastfeed, were younger, had

less education, smoked or had partners that smoked, and did not receive adequate support

after birth. These data provide a better understanding of feeding patterns, and indicate that

there is a clear need for nutrition education programs to increase cornpliance with the CPS

guidelines. To mâximize their impact in creating supportive environments, programs should

involve mothen in the target group, their partnen, close family and fi-iends, and the health

professionals who work with these women.

Acknowledgments

First and foremost, 1 would like to thank the mernbers of my thesis cornmittee

for their dedication to me over the past two years. As the entire thesis was conducted in

Ottawa, they made the extra effort to be available for telephone conference calls, and to

respond to electronic mail.

My supervisor, Dr. Judith Read Guernsey, has been a tremendous source of support

and guidance in developing and conducting my thesis. Dr. Michel Jo fhs provided valuable

advice on statistical methods and programming, as well helping me to translate scores of

numbers into meanin@ words. Dr. Debra Reid of the ûttawa-Carleton Health Department,

was instrumental in providing advice on nutritional issues as wel1 as getting the necessary

idonnation Eom the Ottawa-Carleton Health Department.

1 would also like to thank Nicki Sirns-Jones and the Cornmunity Health Research

Unit at the Ottawa-Carleton Health Department for use of the Infant Care Survey data, as

well as the mothers who participated in the surveys.

Finally, 1 would like to thank the Faculty of Graduate Studies at Dalhousie University

for granting the travel h d s , in order to make the necessary trips to Halifax, and to my

supenisors at Heaith Canada for allowing me to work part tirne so that 1 could conduct my

thesis.

1. Background and üterature review

1.1 Introduction and rationale

One of the most important factors in conûibuting to, and maintainhg health is

nutrition. The human brain has only one opportunity to grow properly [l]. Because of the

rapid period of brain development that occurs fiom the last trimester of pregnancy until 18

to 24 months of age, the nutrients received during this penod are the most important in the

entire life span. The body's other organs and tissues undergo a similar growth spurt, thus

adequate nutrition is required for optimal growth and development. Lnfant feeduig consists

of two main elements: breastmilk and/or formula and beikost (al1 food other than human

milk and formula). Breastmil. andlor formula is usually nutntionally sufficient until six

months of age. Past this age, human milk alone is unlikely to provide adequate energy and

to meet mineral (imn) and vitamin (vitamin D) requirements [Z] . Solid food[a] and liquids

(water, juice, mik) ensure that nutritional needs are covered afier this tirne. Because of the

importance of solid foods during this critical period in the infant's overall growth and

development, it is essential to undentand the factors contributing to early solid food

introduction.

Canadian studies from the past 30 years tell us that in some cases, caregivers do not

follow the CPS guidelines. Mothers are usually the primary caregiver, however, they do not

always have full lmowledge and understanding of the infant's nutritional requirements. In

fact, some mothers are more Likely to follow feeding advice given by fiiends than they are

a For the purpose of this paper, solidfood or solids refers to food other than breast milk, formula, or other milks (whole cow's millr, 2% rnilk, etc) but does not include juice or water. Early soli& refers to the inîroduction of such foods before f o u months of age.

2

the guidelines [3]. Therefore continual assesment and review by health professionals of the

infant feeding practices of the primary caregiver are critical.

The infant feeding practices in Ottawa-Carleton have not been reviewed for over a

decade. In addition, none of the Canadian literature and very few studies elsewhere have

attempted to assess the effect of socio-demographic factors and breastfeeding history on the

introduction of solid foods. This study will provide an understanding of infant feeding

practices, specifically the introduction of soiid foods, in Ottawa-Carleton fiom 1988 to 1996.

A better howledge of feeding patterns which are not consistent with the CPS guidelines,

will guide policy makers in creating an environment which promotes healthier infant feeding

practices. As well, this study will help in developing appropriate education programs for

mothers (and mothers-to-be) and their partnen, and for the health professionals who work

with them.

There is increasing evidence that intervening at cntical stages or transitions in the

development of children has the greatest potential to positively influence theü later health

and well-being [4]. Healthy child development is an essential element in working towards

population health, and is one of a range of individual and collective factors, known as the

deternllnants of health. The compiex interactions among these factors determine a

population's health and well-being.

In Canada, the 1997 Federal Budget and the release of the National Forum on Health

[5] have highlighted the importance of investing in children's health. In the 1 997 Federal

Budget, the govenunent announced an additional $100 million over three years for two

community-based children's programs. The Forum recommended that governments develop

and implement a broad and integrated child and family strategy encompassing both programs

3

a d o r services and incorne support. In addition, Nutrition for Health: An Agenda for Action

[6] encourages the integration of nutritional considerations into policy and program

development for communities across Canada.

1.2 Trends in solids introduction

In the early 1900s, infants were seldom introduced to solid foods before one year of

age [7,8]. However, due to changing attitudes and the availability of formula, solids were

introduced at increasingly early ages during the 1950s and '60s, such that the rnajority of

Uifants received solids between one and two months of age [9].

The early introduction of solid foods is closely related to the trends in breastfeeding.

It has been shown that breastfed babies are introduced to solid foods significantly Later than

infants who are formula fed. This will be discussed in greater detail. in the early 1 WOs,

most infants in the United States were fed beikost by the age of six weeks [IO]. An increase

in the rates of breastfeeding during the 1970s and '80s was accompanied by the later

introduction of beikost [Il]. Although the literahve in Canada during this time is not as

extensive as that in the United States, similar trends have been reported [12, 131.

1.3 Trends and infant feeding practices in Canada

From 1965 to 1971, the introduction of non-milk solids occurred at a national median

of one month; between 80-90% of infants were introduced to solids by three months [12].

This corresponds with surveys conducted in the 1970s in Newfoundland [14] and Québec

[15] in which solids were introduced to 43% of infants by one month, and at a median of

three weeks, respectively. In Ontario, 38% of infants received solids by one month of age

WI*

In Toronto and Montreal in 1977-78, the media. age of solids introduction was

4

slightly l a s than two months; 64% of infants were receiving solids by one month of age, and

79% by three months [17,18]. During the same period, similar rates were fond in Manitoba

[19]. By one month of age, 34% of infants had received solid foods and by three months,

only 22% of infants had not received any solids. In Alberta during the early 1980s, 59% of

four month olds had been given solid foods [20]. A national study in the early 1980s

reported that the median age for introducing solid food was three months [12].

By 1984-85, the median age of solids introduction was four months in a Toronto

sample; 42% of infants received solids at three months of age [2 11. In Ottawa-Carleton at

this tirne, the mean and median ages of introduction were 4.3 and 4.0 months, respectively;

34% received solids at three months [22].

During the 1990s, the age of solids introduction waç later still. For example, in

Vancouver, most infants were introduced to solid foods between four and six months [23].

However, there continued to be instances in which soli& were fiequently introduced before

the recornmended time, as reported in Vancouver [23], Hamilton- Wentworih [24], Québec

[25,26] and Sudbury [27].

The above studies (summarized in Appendix 1) indicate that Canadian infants are

receiving solid foods at an increasingly later age and that their caregivers seem to be tending

towards the CPS recommendation[b] of four to six months. However, in the absence of a

national survey in recent years, the trend towards a later introduction of solid foods can not

be assumed to apply across Canada.

b The CPS recommendations or guidelines refers to Nutrition for Healthy Tenn Infanfi by the Canadian Paediaûic Society, Dietitiam of Canada and Health Canada, released April24, 1998.

5

The literature review was conducted on Medline [28] fiorn 1982- 1998, using the

following search words: breastfeeding, infant food, infant nutrition, weaning.

1.4 Pediatric guidelines in developed countries

in the late 1970s and early 1980s, several countries issued guidelines sirnilar to

Canada's on infant feeding. Before this tirne, the recommended age of weaning was not

consistent and varied h m two to three to six to nine months 1291. The pediarric guidelines

in many countries now share a cornmon approach that infants should not be introduced to

solid foods before the age of three or four months, and that the optimal time is between four

and six months [30, 3 1, 321. M e r six months of age, a diet exclusively of milk is usually

hadequate to meet nutritional needs to maintain optimal growth and health. When solids are

htroduced they should be regarded as a complement to breastmilk or fomula, and not as the

main component of the diet itself. Otherwise, the infant may be at risk for nutritional

imbalance or deficiency.

1.5 Canadian Pediatnc Society guidelines

The 1998 CPS guidelines stress that the approach to infant feeding should not

become too precise or mechanistic. Given that every baby develops at a different rate, the

guidelines shouid be regarded as estimated tirne-fhrnes only [30]. Because of the infant's

chewing and swaIlowing abilities, and the development of digestive, absorptive and immune

processes, breastmilk is the ideal food for the tust few months of life [33]. The CPS

recommends that infants be exclusively breastfed for at l e s t the fint four months of life and

that breastfeeduig may continue for up to two years or beyond [30]. Iron-fortified formula

is recommended in the instance when breastfeeding is not possible. Whole cow's milk

should not be introduced until an adequate amount of solid food containing iron and vitamin

6

C is included in the infant's diet, preferably at 9 to 12 months of age [34]. Partly skimmed

milk (1% and 2%) is not routinely recommended in the fint two years [30]. Skim mik is

inappropnate in the h t two years [30]. The CPS recommends that solids be introduced

between four and six months of age, according to the developrnental readiness of the infant.

The f k t solid food given to infants should be non-allergenic and supply energy and

provide iron. Traditionally, iron-fortified rice-based cereals are the first to be introduced.

The order of introduction usually follows the pattern of cereal, foliowed by vegetables, f i t ,

and then meats. Meats should be introduced last as they have a higher solute load and

protein content. New foods should be introduced one at a tirne, separated by several days.

This separation allows allergies and intolerances to be detected, and easily identified. The

CPS recommends that salt and sugar should not be added to infant foods. Certain foods

should not be fed to babies in their fust year. For example, honey may contain spores

presenting the risk of infant botulism.

1.6 Basis upon which guidelines are developed

The introduction of solids is a complex process, with nutritional, physiological and

immunological consequences. Solids introduction should correspond with the infant's

physiological and neuromuscular maturation which usually occurs around four months. In

other words, the infant should be ready to accept solids before they are introduced.

Readllless depends on the matunty of the infant's gastrointestinal, rend and immune systems

[33,35,36]. The introduction of solids should occur when the infant's hunger is clearly no

longer satisfied by breastmilk andor formula alone [37].

Lebenthal [37] has reported that the young infant's digestive systern cannot handle

foods other than milk in the early months due to the lack of pancreatic amylase for the

7

digestion of starch. The diversity of the infant's diet is also limited by the neuromuscular and

physiological maturity: the extrusion reflex, the inability to chew and for the tongue to pass

foods from the b n t to the back of the mouth, the lack of head control, the gastrointestinal

reflux (regurgitation), the indigestion of fibres, and the rend inability to process high solute

loads. To prevent overfeeding, parents should be encouraged to stop feeding their infants

at the earliest sign of satiation. To do so, infants must be able to communicate. By five to

six months of age, infants have neuromuscular control of the head and neck and are able to

indicate a desire for food by leaning forward and opening the mouth, and when satisfied, they

can tum away or lean back. Earlier feeding of solid foods has been described as a type of

forced feeding [3 51.

The infaat must learn how to chew and swallow solid food, and become accustomed

to new tastes. There may be a window of sensitivity during which the acquisition of new

functions is particularly easy for the infant. For exarnple, the acquisition of chewing may

be more difficult at a later period than during the t h e when the chewing ski11 is emerging.

There is no evidence that the introduction of beikost before four to six months promotes

psychomotor development.

1.7 Influentid factors in solids introduction

A feeding scheme could be developed solely on the bais of the infant's development.

However, there are other cultural, psycho-social and historical factors which cannot be

isolated from the feeding habits and socio-cultural status of the whole population. The

history of the chmging pattern of infant feeding iliustrates the complexity of the subject [38].

In families of low socio-economic status, early introduction of solids often occurs.

This is due to a complex interplay of factors which can include a working mother who cannot

8

breastfeed or afTord formula, and therefore introduces solid foods early. Often, early

introduction has been associateci with low family income and mothers who have little to no

post-secondary education. This issue is discussed at greater length below.

1.8 Advantages and disadvantages of the early introduction of solid foods

The early introduction of solid foods does not usually have added nutritional value,

as breastmilk or commercial infant formula can provide al1 of the necessary nutrients [39,

401. In fact, purported advantages of early solids introduction have not been substantiated

[19, 37, 391. Such alleged advantages include: facilitahg speech by developing oral

stnictmes, accelerating growth, developing taste and acceptance of a varied diet later in life,

and having the infimt sleep through the night [41]. Thus, there do not appear to be any

benefits to the introduction of solid foods earlier than the recornmended age of fou. to six

months. There are however, several disadvantages. It is ironic to note that the early

introduction of solid foods during the mid 20th century was likely beneficial for infants. The

irony &ses because the formulae at that time were cowiderably higher in protein,

electrolytes and rend solute load than is considered optimal today [42]. The solid foods

were beneficial because they diluted the formula's concentration.

The pediatric guidelines discourage the early introduction of solids because of

potential health risks, either immediate or later in life. Fomon [35] has speculated that some

adverse health effects may be too subtle to detect in infancy or even childhood, and that these

effects may becorne apparent much later in life. Unfortunately, little is h o w n about the long

term consequences of infant feeding practices. Prospective cohort studies which follow

infants into adulthood would shed light in this area; to date none have been conducted. A

non-medical disadvantage is the added cost and economic strain, especially for low-income

9

families. Diseases that have been studied in association with the early introduction of solid

foods include: (a) allergies including eczema, (b) iron deficiency, (c) hypernatremic

dehydration, (d) hypertension, (e) obesity, and ( f) atherosclerosis.

Due to the immaturity of the gut's local immune system during early infancy, the

early introduction of solids rnay increase the likelihood of allergies [43], particularly for

families in which there is a history of atopy [44,45]. For such families, breastfeeding is

recornxnended, cow's millc products and solids should not be introduced until four to six

months, and certain allergenic foods should be withheld for the h t nine to 12 months.

Diseases such as eczema and asthma have been studied in relation to the age of solid food

introduction. Forsyth [46] and Fergusson [47] found an increased incidence of eczema

among children given solids early. The incidence of childhood asthma was not influenced

by early solid feeding practices [48].

Infants are able to absorb more iron nom breastmiik compared to formula or other

foods. Therefore, term infants who are breastfed for the fint six months of life are not at nsk

for iron deficiency. Solids, however, may compromise the bioavailability of iron firom

human mik [49,50].

Infânts have a limited renal concentration ability. Hypematremic dehydration is

caused by an increased solute load kom the early use of 2%, 1 % and/or skim milk, the early

introduction of solid foods and the addition of salt to these foods. A reduction of these

feeding practices is believed to be responsible for the marked decrease in the incidence of

this condition. For example, in Great Britain the incidence of hypematremic dehydration

decreased h m 63% in the late 1960s to 2 1 % a decade later [5 11. The introduction of solids

before four months does not seem to present a problem because babies are satisfied with such

10

small amounts that hyperosmolality is rmlikely to occur [52]. However, there is much debate

surroundhg the quantity of solids fed to infants before the recommended age.

There is evidence to suggest that high sait intake is associated with a higher

prevalence of hypertension [53,54]. Although salt intake may be only one of many factors

contributhg to hypertension, it is hypothesized that restricting s d t intake fkom infancy rnay

protect people who are at risk of developing the disease [55].

There is substantial debate as to whether the early introduction of solids leads to

obesity later in life. Poskin [56] concluded that it is not the age of weaning which is

associated with obesity, but rather the attitudes toward food and meals leamed by infants

during the weaning process. There is evidence to suggest that uifant obesity is a poor

predictor of obesity later in life [57,58]. This is because most babies outgrow their 'fatness7

by the time they are toddlers.

A consistent association between infint feeding practices and obesity later in life has

not been established. In order to examine this relationship, several additional factors must

be taken into consideration. For example, breastfed and formula-fed infants have different

growth patterns [59,60]. When compared with current growth charts, breastfed iafants grow

more rapidly (gain more weight) in the h t two months of life and less rapidly from three

to 12 months. In the second year of life, breastfed infants gain weight more rapidly than the

reference so that by 24 months of age, their average weight is close to that of the reference

media. [61]. These studies indicate that diet specific growth charts are needed. Studies have

shown that formula-fed infants are introduced to solid foods significantly earlier than those

who are breastfed; this will be M e r discussed. Studies which have separated the effects

of formula feeding nom those of early solids have found that the eady introduction of soiids

11

is not associatecl with obesity [46, 52, 621, while other research does indicate that an

association exists [63]. Only Forsyth 1461 controiled for use of tobacco by the rnother, which

is linked with a decreased birth weight for infants.

In terms of the age of onset, atherosclerosis is regarded as a pediatric problem [64].

The association between hyperlipidaemia and atherosclerosis, and the fact that a reduction

in adult fat consumption is recommended, has generated a great deal of controversy with

respect to the type and amount of fat in the diets of infmts and children. Those in favour of

a strict policy on the intake of fat in early life argue that reduced fat intake at this time may

prevent the later development of cardiovascular disease. There is, however, Iitt le evidence

to support reducing fat intake for normal infants [65]. The uifant is nutntionally vuinerable

due to the rapid growth and development which occur during the h t two years of life. The

main concern with a low-fat diet is the risk of impaired growth and development through a

restricted energy intake. A high fat diet (approximately 50% of energy kom fat) during

infancy helps to ensure an adequate intake of energy and essential fatty acids. Because

infants and young children c m only consume a limited amount of food, energy intake will

be hufficient to cover energy requirements on a low fat diet. in Canada, it is recommended

that, for their first two years of life, nomal infants be excluded from any dietary

modifications recommended for cardiovascular disease [66].

1.9 Rationale for variables included in analyses

The introduction of solid foods bas been studied on an international scale, and similar

patterns and relationships have been reported worldwide. This section will focus exclusively

on Canadian data, and will provide a rationde for the variables that should be included in the

present study.

12

The timing of first solids introduction is just one of many factors in infant feeding

practices which contributes to an infant's nutritional status. Other factors include: the use of

breastmilk, formulas, cow's milk including whole cow's milk (homo), 2%, 1 % and skimeci,

the quantity of complementary foods and the nutritional composition of these foods. These

factors are al1 related to the introduction of solids. This is especially evident with

breastfeeding. As will be discussed below, women who breastfeed their infants introduce

solid foods at a significantly later age than women who do not breastfeed.

Despite regional differences, overall patterns in Canada show an increase in

breastfeeding initiation, followed by a leveling off. Initiation rates increased fiom 25% in

1970 [12] to a national average of 7O-80% in the 1980s [ 13,671. Since their peak in the early

to mid 1980s, initiation rates in the late 1980s and early to mid 1990s have stabilized or

increased only slightly [68]. Despite the relatively high initiation rates, exclusive

breastfeeding duration is still well below the recornmended four months.

The increased prevalence of breastfeeding is accornpanied by a trend towards the later

introduction of solid foods and unmodified cow's rnilk, as previously discussed. ûver the

past 20 years, Canadian studies have reported a consistent association between a lack of

breastfeeding and the early introduction of solid foods [12, 13, 16- 19'22-27,69, 701. These

stuclies do however, have several limitations. The most obvious is that none of these studies

atternpted to assess the effect of socio-dernographic factors and breastfeeding history on the

introduction of solid foods,

An association between breastfeeding and early solid introduction is observed t h e

and again. In a national study [12] in the early 1970s, breastfeeding rnothers tended to

introduce solids later (median of three months) when compared to bottle feeders (median of

13

one month). Infants fed a combination of breast and bottle had a median age of two rnonths

[12]. While these results are useful, they are descriptive in nature and do not control for

explanatory variables.

Statistically signincant differences between breastfeeding and eady solid introduction

were reported by Escott [16], Bramble [69], Clark [19], Greene-Finestone [22], Spigelblatt

[25], and Bourgoin [27], although there were some limitations to each of these studies.

Escott's sample excluded unwed mothers, and the representativeness of the sample was not

specified [16]. Bramble failed to provide information about the sample's representativeness,

and when and how the sample was collected [69]. In addition, multivariate analysis was not

used and therefore did not control for any explanatory variables. A prospective cohort study

from Manitoba did not compare mothers lost to follow-up with those who remained in the

study [19]. Nor were the data collected unifomly; telephone, mail and home interviews

were al1 used and there was no cornparison of these different methods. Greene-Finestone did

not employ multivariate analysis to control for explanatory variables, nor was the sample

representative of the Ottawa-Carleton population [22]. A sample fiom Montreal was taken

£kom only middle class families, therefore a cornparison of the study's results with the

generd population would not be useful [25]. In addition, t-tests were used to determine

which mothers fed eady solids; multivariate analysis was not conducted. FinaIl y, Bourgoin

[27] included only those mothers who were breastfeeding before hospital discharge;

multivariate anaiysis was not used.

Even in cases where the association between breastfeeding and early solid food

introduction was not significant, the same trend prevailed; breast-fed babies were introduced

to solid foods later than those who were bottle-fed [26]. The major Limitation of this study

14

was the low response rate (23%) and the fact that the data were collected fiom a sample of

Québec pediatricians who were not representative of pediatricians in Québec. Several

studies that did not speciQ statistical signi ficance also found the same trend [ 12- 1 3, 1 7- 18,

23-24,701. Similarly, a national s w e y reported that at two rnonths of age bonle fed babies

were introduced to solids earlier than breastfed babies, 40% versus 20% respectively [13].

In summary, the limitations of these studies include (1) results that are only

descriptive in nature, and therefore do not attempt to examuie the effect of socio-

demographic factors or breastfeeding history on the introduction of early solids [12-13, 17-

18, 23-24, 701, and (2) a sample that is not representative of or was not compared to the

general population [17- 1 8,23-241.

In addition to the association between solids and breastfeeding, studies have found

that women with certain socio-demographic characteristics are more likely to breastfeed.

These women are more likely to be older, better educated and have middle to hi& family

incomes. They are more likely to have a partner and be a non-smoker [68, 7 1, 72, 731.

Women with one or more of these characteristics, for example, a higher education and family

income, are significantly more likely to breastfeed when compared to women with a lower

education and income.

There is evidence to suggest that these socio-demographic characteristics are

associated with the introduction of solid foods. In Ottawa-Carleton in 1984, the early

introduction of solids (< three months) was inversely related to socio-economic status [22].

Spigelblatt [25], Clark [19] and Escott [16] reported similar trends in Montreal, Manitoba

and Ontario, respectively. A national survey indicated that mothers with the lowest

education tended tu introduce solids earlier (2 1 % in the first month) compared with more

15

educated mothers (48%) [13]. The Limitations pertaining to these studies have been

discussed above.

In summary, previous Canadian research suggests that factors such as breastfeeding

history, age, education, income, and smoking status play a role in solid food introduction.

These variables should therefore be included in the present study.

2. Methods

2.1 Research objectives

The objectives of this study are:

(1) To describe infant feeding practices during the first s u months of life in Ottawa-

Carleton, with a focus on the introduction of solid foods, and;

(2) To detennine the relationship between socio-demographic characteristics and

breastfeeding practices of iafants' mothers, and the introduction of solid foods before

four months of age.

2.2 Study design, data collection and verification

The analyses use data nom the Ottawa-Carleton Health Departmenr Infant Care

Surveys conducted in 1988, 1992 and 1996 (Appendices 5,6 and 7). Each of these cross-

sectional surveys includes a cohort of parents with six month old babies. In 1988, the

surveys were conducted in November and December; the infants were bom between Apnl

30 and June 2. In 1992, mothers were surveyed in November and December; the ùifant's

birth dates ranged £kom May 25 to July 6, 1992. The 1996 surveys were conducted in

October and November; the infants were bom between Apnl 1 and June 30.

In 1988 and 1992, the sampling W e was drawn fiom the Physician Notification of

Births (PNOBs). nie sampling frame was created by a cornputer-generated random list for

the tirne periods specified above. Al1 live births in Ottawa-Carleton, including home births

are found within the PNOBs. The 1996 sample was drawn fiom the Liaison R e f e d Foms

(LRFs), by a cornputer-generated randorn list of the births between April 1 and June 30. The

LRFs consist of 95% of dl live births in the Ottawa-Carleton region hospitals, but they do

not include home births. The missing 5% occurred on a random basis.

16

17

Babies not included in these records are home-births (1 996), and families who have

moved to the region after childbirth. The number of home births in 1996 is estimated to be

less than 1% of al1 births in the region. This figure is based on data fiom the two regional

midwifery groups [74, 751 and the total births in Ottawa-Carleton [76]. The number of

families who moved to the region after childbirth was not recorded. Statistics Canada data

reported that in Ontario, a small percentage of households did not have telephones (1% 1988;

< 1 % 1992; 1 % 1996) [77-791. These data were not available for Ottawa-Carleton. The

number of households with 'new' mothers is likely much smaller than 1 %. Therefore, the

number of mothers that were excluded fiom the s w e y s because they did not have a

telephone is negligible.

For each of the three samples, letters were sent to dl farnilies uiforining them of the

survey. The data were collected by a telephone survey conducted by one of six public health

nunes (1 988), or by one of two interviewers (1 992 and 1996).

In each of the surveys, the intewiewer made six attempts at various tirnes of the day

to reach the farnily. After the surveys were completed, data entry clerks coded, entered and

cleaned the data. The data were entered into an SPSS file, using the double entry method to

ensure correct entry. The data were converted to SAS for the purpose of this study.

The 1988 survey focused on parent and child health, whereas in 1 992 and 1996, the

focus was on infant care. Since the responsibility for the infant's feeding rests rnost often

with the mother, only mothers were asked to respond in 1992 and 1996. In 1988, a small

percentage of responses were fiorn fathers (3%), dthough the majority were fkom mothen

(97%). The fathers' responses were compared with those of the mothee. Based on the

descriptive analyses, it was decided to include the fathers' data.

18

The variables included in the analysis are described in Table 1. In addition, the

baby's and mother's health since the baby's birth, the baby's birth weight, and the language

spoken in the family home were uiitially included in the analysis. However, because these

variables were not significantly related to the introduction of solid food in any of the three

cohorts, they were excluded ffom M e r analysis. When the same variables were collected

fiom year to year, the 1992 and 1996 questions were based on those fiom 1988, and were

phrased in a similar manner. The 1988,1992 and 1996 data had not yet been analysed in the

manner outlined in this thesis (Appendix 2). This thesis includes an in-depth analysis of

these data,

2.3 Definitions

The following definitions were used for the purposes of this study.

Solid foods or solids were defined as any food other than breast milk, formula, or

other milks (whole cow's mi4 2% m i 4 etc) but do not include juice or water.

The early introduction of solid foods was d e h e d as the introduction of such foods

before four months of age.

Exclusive breastfeeding was defhed as breastrdk being the only food the infant was

fed.

Cow's rnik was defined as homogenized, 2%' 1%' skim or powdered milks.

2.4 Interna1 validity

Al1 the in te~ewers were trained in proper telep hone interviewing technique; the

questio~akes were pre-tested. In 1988, the reliability of the questionnaire was assessed by

19

having 30 randomly selected families nom Onawa-Carleton complete the questio~aire

twice, with two weeks separaîing each event. There was approxirnately 90% agreement on

the answers given. The same interviewer conducted both surveys, and did not have the £ k t

questionnaire at hand when conduchg the second.

The 1992 survey was a revision of the questionnaire used in 1988. In tuni, the 1996

survey was a revision of the questionnaire used in 1992. In both cases, public health nurses,

nutritionists and managers fiom the Parent Child Health Section of the Ottawa-Carleton

Health Department were invited to comment on the questionnaire, and provided excellent

suggestions. The questionnaires were also piloted with 10 women pnor to their

implementation in order to discuss difficulties and to clarify any arnbiguities.

2.5 Ethics review and confidentiaüty issues

AI1 of the surveys were reviewed and received approval by the Ottawa-Carleton

Heaith Department Research Ethics C o d t t e e (Appendix 3). Consent for participation was

given verbaily by the mother or father at the t h e of the telephone interview. The surveys

were coded by the data clerks to ensure confidentiality.

2.6 Sample size and power

The 1988, 1992 and 1996 surveys included 373,330, and 338 six month old babies,

respectively. Using Fleiss's [80] two-tailed test on proportions (p,=0.25 and p,=0.65), with

a probability of 0.05, and a power of 8O%, a total sample size of 56 infants would be needed

to detect a difference between soiid food introduction before and after 4 months, based on

breastfeeding exposure. If the power was increased to 99%, a total sample size of 1 14 would

20

be needed. Therefore, this data base has nifncient power even when stratimg the data, or

for multivariate analysis. The proportions above are based on a study in Ottawa-Carleton

in which 25% of breastfed and 64% of never breast-fed UIfants were introduced to cereal

before 4 months [22].

2.7 Data anaiysis

The statistical software package SAS [8 11 was used to conduct most of the analyses

in this study. EpiInfo [82] was used to perform the chi-square tests to detect trends over

t h e .

2.7.1 Descriptive

The descriptive data generated here provided sufficient information to detect if any

trends exist over the three surveys (chi-square tests for trend). In each of the cohorts, there

were infants who had not yet been given solid foods when the survey was conducted. Their

age at introduction was never collected and it would be inaccurate to assign a value. These

children were therefore excluded fiom the calcdation of mean age of solid food introduction.

The true mean age, which would include infants given solid foods when they were older than

six months, is therefore greater than the value reported in Table 7.

Chi-square tests were used to determine if there were significant differences in

matemal and milk feeding characteristics in relation to the age of introduction of solid foods.

The matemal and milk feeding characteristics were stratified into various categones (see

Table 1). In some instances the sample size per strata was too small and different groups

were established. For example, the number of infants given cow's milk before six months

21

of age in 1992 and 1996 was too small to include as a category in the chi-square test. These

infants were therefore excluded fiom the tests, and were instead descrïbed individually. In

another instance, the rnother's age was initially divided into three groups (c 20,20-29 and

>29 years). Because there were not enough women in the youngest group, the age groups

were changed accordùigly.

The age of solid food introduction was categorized in months. In 1988 and 1992, the

age of solid food introduction was recorded in months. In 1996, however, the age of solid

food introduction was recorded in weeks. This data was then categorized in months

according to the foilowing format: 1-4 weeks = 1 month; 5-8 weeks = 2 months; 9-12 weeks

= 3 months; 23-16 weeks = 4 rnonths; 17-20 weeks = 5 monîhs; 21-24 weeks = 6 months;

greater than 24 weeks was considered to be greater than 6 months. Categorizing the data

fiom weeks to months may have caused some misclassification of the data, specifically,

during the third month. For example, 12 weeks of age is closer to four months than it is to

three. However, because the 1996 mean age of solid food introduction does not differ

significantly fiorn the 1988 and 1992 cohorts, it does not appea. that this was a significant

problem.

The rnilk feeding variables were catergonzed as dichotomous for each type of m i k

being fed at birth, or six months of age. For exarnple, at birth there were three milk feeding

variables: breastmilk at birth (yedno), formula at birth (yedno), breastmilk and formula at

birth (yedno). These were considered as independent variables in order to examine them

separately. The rationale for this approach was based on the complex issues surrounding

22

breastfeeding, and that it is not ody a feeding method, but also suggests a social and cultural

environment.

2.7.2 Analytical

Al1 of the hypotheses were tested using a two-sided test at the alpha=û.05 level of

significance. The 5% level of significance would yield 95% confidence intervals in the

regression models; 95 out of 100 times the parameter estimate would fall within the

comesponding confidence interval.

For each of the three populations, the relationship between matemal characteristics

and infant feeding history, and the age of solid food introduction was assessed using the chi-

square statistic. Comparing the pattern of chi-square values for the given characteristics

across the three cohorts did not reveal a sunilar pattern, therefore the data (of the three

cohorts) were not combineci. The coholts were therefore analysed separately in al1 univariate

and muhivariate analyses. The three s w e y years served as an additional level of

stratification; differences were assessed using the chi-square test for trend.

Univariate analysis, using logistic regression with one independent variable, was used

to assess if significant associations existed between matemal (age, marital statu, education,

farnily income, smoking statu, support) and infant characteristics (mik feeding at birth and

at six months) and the likelihood of solids being introduced before four months of age.

2.7.2.1 Decision rules for inclusion of variables in multivariable models

Logistic regression was used to build a multivariable models that predicted the early

introduction of solid foods. The outcome variable was dichotomous, Le., ye%o with respect

23

to infants being inwduced to solids before four months of age. Logistic regression was used

to control for explanatory variables. Forrnal SAS forward, backward or stepwise regression

techniques were not used.

The following steps were taken in building the multivariate logistic regression

models. (1) The variables were forced into different models, by adding one variable at a

time. In building each model, milk feeding at birth, or at six months was

entered as the first variable. A milk feeding variable was added first because

of the importance of this factor in relation to the introduction of solid foods

as reported in the literature, and as a result of the statistical findings in

Section 3.3.

For those rnilk feeding variables which were significantly associated with solid food

introduction @r0.05), each of the socio-econonic variables were individually

entered as the second variable; each generating a separate model.

If the milk feeding variable and a socio-economic variable were both significantly

associated with the early introduction of solid foods, based on a significance level of

10.05, then a third socio-econornic variable was added.

This process was continued until al1 of the potential models had been constructed,

and it was detemllned which models had variables for which al1 were significantly

associated with early solids introduction.

Models were also built without a mik feeding variable, by the method described

above, to determine if this variable was influencing the significance of the socio-

economic variab les.

In models for which aU variables were signincantly associated with early solid food

introduction, the adjusted odds ratios and the correspondhg 95% confidence

intervals were examined. If the confidence interval included 1.00, the variable was

not considered to be significant in the model.

For each of the three cohorts, several models were generated. These models are

discussed, and what is beiieved to be the best model is suggested. Regression

analysis was used to determirle the relationship between the independent categoncal

variables.

Several models were constructed in which al1 variables were significantly associated

with the age of solid food introduction. The -2 log likelihood for each of these

models was examined. The model with the highest -2 log L indicated the mode1 that

had the best fit. In addition, regression analysis was conducted to determine the

relationships between various independent socio-economic variables. These

relationships, as wel: as knowledge and questionhg of the biological meaning helped

to choose the best models.

Interaction variables were calculated for age and income, and age and education;

these were added to their respective models. None were significantly associated with

solid food introduction and were therefore dro~oed fkom the model.

Variable Description Measurement unit

1 Potential outcome variable

Solid introduced < 4 months of age I categorical O= no solids < 4 1= solids <4

1 Poten tial independen t variables

I Breastmilk at birth

Formula at birth

Breastmilk and formula at birth

Breastmilk at six months

Formula at six months

I Cow's milk at six months

categorical I O=not exclusively breastfed at birth l=exclusively breastfed at birth

categorical l O=not exctusively formula fed at birth l=exclusively formula fed at birth

categorical O=not breastfed and formula fed at birth l=breastfed and fcrmula fed at birth

categorical I O=not breastfed at six months l=breastfed at six months

categorical O=not (exclusively) formula fed at six months l=(exclusively) formula fed at six months

categorical I O=not fed cow's milk at six months l=fed cow's milk at six months

1 Variable 1 Description 1 Measurement unit

1 - - - - --

1=< 23 years 2=23-29 years 3= r 30 years

Mother's marital status I categorical O=no partner (single, separated, divorced) l=partner (married/common-law)

Mother's education categorical 1= s high school 2= some post-secondary 3= coliege graduate 4= L university graduate

Mother9s parity categorical 1=1 child 2=2 children 3=r 3 children

Total family income categorical 1=< $20,000 2=$20,000-29,999 3=$30,000-49,999 (1 992 & 1996 only) 4=2 $50,000 (>$3OK in 1988)

Support I help after birth categorical O=mother did not receive supporthelp after birth l=mother received supporUhelp after birth

Mother9s smoking status while pregnant categorical O=mother did not smoke while pregnant I=mother smoked while pregnant

1 Variable 1 Description 1 Measurement unit 1

l Mother's smoking status after birth l categorical l O=mother did not smoke after birth l=mother smoked after birth

ETS exposure at home categorical O=infant exposed to ETS at home l=infant not exposed to ETS nt home

3. Resnlts

3.1 Response rate

The total number of mothers included in the sampling &me is shown in Table 2.

The response rates are quite high (8 1% 1988; 76% 1992; 77% 1996). The three data sets

should be representative of the "new mother" population in Ottawa-Carleton as the samples

were randomly drawn; this is also suggested by the Census Canada data presented in Tables

3 and 4. Despite the high response rates, it would have been desirable to determine if there

was any response bias. However, no data were available on the non-respondents and it is

therefore difficult to know how they differed fiom the sample population.

It was not possible to reach between 15% and 17% of the samples, either because

they changed addresses &er childbirth, did not have a telephone, or were not home to

receive the interviewer's telephone c d . This last possibility, however, is not as likely

because for each survey, the interviewer tried to reach each rnother six different times at

various times of the day. The interviewers were unable to cornplete surveys for 3% and 2%

of mothers in 1992 and 1996 respectively, as the mother did not speak English or French;

this figure is not available fiom the 1988 sample. Although the number of households in

Ottawa-Carleton without telephones is not available, Statistics Canada data for Ontario

suggest that only a srna11 percentage of residences did not have telephones (approxirnately

1 % for each cohort) [77-791.

3.2 Extemal vaiidity

In order to determine if this study's population is a valid sample from which to draw

29

conclusions, it was compared to data fkom the 1 99 1 S tatistics Canada Census [83]. In this

census, fertility was expressed in tems of the number of children ever bom alive to al1

women aged 15 years and over. For the purpose of this comparison, women aged 15 to 44

years were selected. Unfiortunately there is no indication of when these women gave birth

to their youngest child, therefore it was impossible to select 'new mothers', Le., women who

gave birth six rnonths before the census was conducted. This makes the following

comparison difficult and explains only some of the differences between the women in this

study and the Census data Nonetheless, it should give a good indication of whether the

Onawa-Carleton sarnple is representative of the rest of the country. This study's data were

compared with census data from Ottawa-Carleton, the province of Ontario and Canada as a

whole on the basis of marital status, education, and age (Tables 3-5).

With respect to marital status, Table 3 indicates that a higher percentage of mothen

from this study are married compared to the Census data. The percentages of single and

widowed mothers is about the same, whereas the number of separated and divorced rnothers

h m the Census is much higher. These differences are likely a result of the amount of time

between the birth of the youngest child and when the data were collected. The Ottawa

Cençus data have a sirnilar distribution to those of Ontario and Canada. Therefore, although

there are slight differences, the distribution of marital status in this study reflects that of

women in the rest of the country.

There is a much higher percentage of Ottawa-Carleton mothers in the younger age

groups, and a much lower percentage in the two oldest age groups when compared to the

30

Census mothers (Table 4). As with marital status, these ciifferences in distriiution would be

a result of when the data were collected in relation to when the mother gave birth to her

youngest child. Therefore, with respect to mother's age, these data reflect that of women

across the country. As shown in Table 5, a greater percentage of Ottawa-Carleton mothers

are University graduates, and a lower percentage have a high school education or less, when

compared to Canada as a whole.

3.3 Description of survey populations

T p e of milk feeding at birth: The prevalence of breastfeeding, either exclusively or

in combination with formula, has gradually increased over the last decade h m 80% to 87%

(Table 6). The increase over the three cohorts is not statistically significant (r test for trend;

pN.05).

Age of solid food introduction: Data in Table 7 indicate that from 1988 to 1996, the

mean age of solid food introduction remained relatively constant, either slightly higher or

lower than four months. Due to Uifants not yet introduced to solids at six months of age, the

hue mean age of solid food introduction in each of the three cohorts is greater than the values

indicated in Table 7.

On a month by month basis, the greatest percentage of infants were introduced to

solid foods at four months of age, as shown in Table 8. In al1 cohorts the pattern of

introduction (month by month) is not normally distributed @<0.005), although the median

and mode have values of four months, and the mea. is approximately four months.

Approximately one f i f i of the infants were given solids by their third month, and the

31

rnajority by their fourth. Between 16 and 27% of infants were introduced to solids at five

months. By six mon& of age, between 91 and 96% of the infants had been introduced to

solid foods. A mal1 percentage of infants (3 to 9%) had not yet received solids at six

months of age.

Age of solid introduction & milk feeding at birth: The pattern of solid food

introduction in each of the mik feeding groups resembles the overd pattern of introduction

(Table 8), with a peak at four months (Table 9). The data are not normally distributed. For

breastfed infants, the distribution is skewed to the nght, whereas for formula fed infants, the

distribution is skewed to the Ieft. More formula fed infants were introduced to solids in their

first four months, when compared to the breastfed infants (x2 test: 1988 pM.05; 1992

p<0.005; 1996 p<O.OOS). It then follows that after four months of age, a greater percentage

of breastfed infants were introduced to solid foods.

Iiifants who were fed both breast rnik and formula at birth, received their first solid

food somewhere in the middle of the two groups. In general, they were given solids later

than formula fed babies (X2 test: 1992 pC0.05; 1996 p<0.005), but earlier than those who

were breastfed (XL test: 1992 pM.05; 1996 p>0.05). These results have been summarized

below in Tables 10a and lob.

Type of milk feeding at 6 months: Data in Tables 1 1 to 13 indicate that breastfeeding

prevalence at six months of age, either exclusively or in combination with formula, increased

nom 32% in 1988 to 46% in 1992 and decreased to 37% in 1996. These changes were not

statistically significant (X2 test for trend: pM.05). The exclusive use of formula continued

32

to increase over this tirne penod (1988: 48%; 1992: 52%; 1996: 59%), whereas the use of

cow's m i k had decreased to the point where very few babia were consuming it (1988: 20%;

1992: 2%; 1996: <1%). The trend was only significant for cow's milk use, not for formula

(X2 test for trend: p<0.005; pXI.05).

Age of solid introduction & milk feeding at six rnonths: At six months of age, infants

were fed either breast milk exclusively (BF) or partidly (BF&FF), formula (FF), or cow 's

milk, as seen in Tables 1 1 to 13. Infants were more likely to have been introduced to solids

before their fourth month if they were fed cow's milk compared to formula at six months;

this difference was statistically significant in 1992 and 1996 (X2 test: 1988 pM.05; 1992

pc0.005; 1996 p<O.005). Infants receiving solids before four months were stah'sticdly more

likely to be receiving formula compareci to breastmilk, at six months (X2 test: 1988 p4.05;

1992 p<0.005; 1996 p<O.005). It is evident that solid food introduction for the BF&FF

infants more closely resernbled that of the BF, and not the FF infants. A summary of these

data can be seen in Tables 10a & lob.

Profileofinfantsreceivingcow'srnilk: In 1992 and 1996,2% and<l%ofinfants,

respectively, were introduced to cow's milk by six months of age, but were excluded fkom

the X2 tests in Tables 21 and 22 because their sample sizes were too small. The

characteristics of those infants given cow's Mllc by six months of age are shown in Tables

14 and 15, and are discussed below.

In 1992, al1 infants fed cow's miUc at six months had been formula fed at birth, and

had been introduced to solid food at two, three or four months of age. These data are

33

presented in Table 14. The mother's average age was 27 years. Seventy one percent of the

mothers had an education level of less than high school; the remainder were college

graduates. Al1 of the mothers had partners. Seventy one percent of the mothers smoked, and

al1 babies were exposed to ETS. The total family incomes ranged from less than $15K to

$38-49K, however three of the seven mothers either deciined to answer, or did not know

their income level. Seventy one percent of the mothers had two children.

In 1996, 12 infants were given cow's milk by six months. These data are presented

in Table 15. Two thirds of the infants were breastfed at birth, and the remainder were evenly

divided between breast milk and formula, and only formula. The age of solid food

introduction ranged 60x11 one to six months, with over half the group having solids before

four months. The mother's average age was 27 years. One third of the mothers were college

or university graduates; the remainder had either some post-secondary education, or less than

high school. Eighty three percent of the rnothers had partners. One quarter smoked during

pregnancy, 42% smoked after bkth, and 50% of the infants had an exposure to ETS at home.

Half of the families had an income of less than $30K, the remainder were divided amongst

the upper income categories. The average nurnber of chikiren per family was 1.6.

Type of milk feeding ai birth and six months: It is evident that almost none of the

infants formula fed at birth were breastfed at six months (cl%), whereas almost a third of

the infants breastfed at birth continued to receive breast milk at six months of age (1988:

32%; 1992: 25%; 1996: 3 1%) (Table 16).

FNst solid food: For those infants introduced to solid foods by 6 months of age, data

34

in Table 17 indicate that cereai was ovennrhelmingly their k t solid food. For each of the

three cohorts, approxirnately 90% of infants were fed cereai as their first solid food. Fruit

and vegetables were the two other first foods, given to a much smaller percentage of the

population (4 to 3%). The distribution of these foods in the k t six months of life is

sirnilar in al1 three cohorts, as presented in Table 18. As the first food, cereal was given

starting at one month of age; vegetables, and then fiuits were introduced at two and three

months, respectively .

Soiid food introduced by 6 months, and milk feeding at birth and at sir months

(1996): Data in Table 19 uidicate that the consumption of a specific food group is not

related to the type of rnilk fed at birth or at six months.

Subsequent solid foodr (1996): Among al1 of the food groups, cereal was introduced

most kequently; cereai and vegetables were given at the youngest ages (Table 20). The

pattern of cered introduction follows that of the first solid. The majority of infants were

given cereal by four months of age, vegetables by five and f i t by six. Meat was introduced

to less than 1% of infants at four months, and to almost 40% by six months. Other grains

and mik products were introduced to only a mal1 percentage of infants; this occurred from

three months onward. Eggs were also given to a small number of infants, at five and six

months.

Maternai and milkfeeding charactenstics in relation to the age of iniroduction of

solid fouds: Mothers who breastfed their infants at buth or were still breastfeeding at six

months, were more likely to introduce solid foods at, or d e r , four months of age, when

35

compared with mothers who did not breastfeed their infants at birth, or who had stopped

b d e e d i n g at six months. These data are presented in Table 21. There was a significant

difference between bredeeding and non-breastfeeding mothers at six months for al1 three

cohorts @<0.005); breastfeeding at birth was significant for two of the three cohorts

(pcO.005); the third cohort had a borderhe level of signi ficance Q~0.05-0.1).

Younger mothers were more likely to introduce solid foods before four months of

age, when compared to mothers in the two older age groups. A dose-response relationship

was evident in all three cohorts, and was statistically significant in 1988 (pC0.05) and 1996

m . 0 1 ) . Wornen with a parîner were more likely to introduce soli& at or aAer four months

of age. This difference was statistically significant in 1988 @<0.05) and 1996 @=0.005).

The greater a mother's level of education, the less likely she was to introduce solid

foods before four months of age. This trend was statistically significant in al1 three cohorts

(1 988 & 1992: pc0.005; 1996: p<O.05). A similar trend occurred in a11 of the cohorts with

regard to family income and the introduction of solid foods. Although only statistically

significant in 1996 @<0.005), as the family's income increased, the percentage of infants

introduced to solid foods before four months of age decreased.

The fiequency with which a mother received help or advice was associated with the

age of solid introduction in one cohort (1996: FO.05-0.1). A pattern for this relationship in

the three cohorts did not emerge. There was a statistically significant relationship between

mother's parity and the age of solid food introduction in 1996 @<0.01), in which mothers

with one child were most likely to introduce solids before four months. However, this was

36

not a dose-response relationship, nor were there significant relationships in the other two

cohorts.

As shown in Table 22, a mother who smoked during, or after her pregnancy was more

Likely to htroduce solid foods before her infant was four months of age. Similady, in homes

in which an infant was exposed to ETS, a larger percentage of infants were introduced to

solids before four months. These relationships were statisticaily significmt in 1 98 8 (p<0.05)

and 1996 @<0.005), and though not always significant in 1992 (pc0.05-0.1 for 'mother

smoked after birth'), the data showed the same trend.

Mother und futher S responses in 1988: A small number of fathers answered the

surveys in the 1988 sample. These data are summarized in Table 23. Based on this

descriptive analysis, there are some differences between the rnothers' and fathers' responses.

Due to the small sarnple size it was not possible to test these differences because categories

contained sarnple sizes less than five. It was concluded that these differences would not

significantly alter the results and therefore the fathers' data were included in the 1988 cohon.

3.4 Relationship between age of solid food introduction and matemal and infant

variables

As show in Tables 24 to 28, several independent variables in each of the three

cohorts had a consistent relationship with solid food introduction before four months of agi:.

The independent variables that had a consistent relationship with early solids introduction

were: breastrnilk at birth, breastmik at six months, education, and age. The univariate

relationships between the dependent and independent variables for each of the three cohorts

37

is illusûated in Table 24. The muitivariable rnodels for the 1988, 1992 and 1996 cohorts are

presented in Tables 25,26 and 27, respectively. A summary of the multivariate associations

for each of the three cohorts is found in Table 28.

With an odds ratio greater than one, the likelihood of an infant being introduced to

solids before four months increased as the value of the variable increased. An odds ratio of

less than one indicated that the variable had a protective effect against an infant being

intmduced to solid foods before four months of age. If the 95% confidence interval included

1.00, the variable was not considered to be significantly associated with the age of solid food

introduction.

3.4-1 1988 survey

In univariate analysis, receiving breast milk at six months and cow's mik at six

months were the mik variables most significantly associated with solid food introduction

before four months (Table 24). Infants were more than twice as likely (OR=2.50,

95%CI=1.40-4.41) to be given solids before four months if they then received cow's milk at

six months, and less than half as likely (OR=0.37,95%CI=O. 19-0.68) if they continued to

receive breast mik at six months. Mik at birth was not significantly associated with age at

introduction.

In a logistic regession model in which breastmilk at six months was the first variable

to be included, education (model 1 ), age (model 2) and marital status (model 3) resulted in

a model in which both variables were significantly associated with solid food introduction

before four months. These data are presented in Table 25. For each model, there was a

38

protective effect between these variables and age of introduction. Infants were less likely

to have received solids before four months if their mothers continued to breastfeed them at

six months, and if their mother was more educated (OR=0.76,95%CI=0.61-0.94), or older

(OR=0.94, 95%CI=O.88-1-00), or had a partner (OR4.38, gS%CI=û. 15- 1.01). When

developing fùrther models with these variables (Le., breast m i k at six months, age, x) there

were no models in which ail three variables were significantly associated with age of

introduction. 'Breastmiik at six months, education' (model 1) was chosen as the best model

because its confidence interval did not include one.

In a logistic regression model in which cow's milk at six months was the fïrst variable

to be included, education (model 4) and age (model 5) were the only variables to be

significantly associated with solid food introduction. These models are presented in Table

25. Education and age had a protective effect against early solid food introduction (OR=0.76

and 0.94 respectively), while being fed cow's milk at six months increased the likelihood

(twofold) of the infant having been given solids before four months. There was no model

with three variables in which al1 were significantly associated with age of introduction.

'Cow's milk at six rnonths, education' was chosen as the best model (mode1 4) because its

confidence interval did not include one.

To test if the mik feeding variables were associated with and thereby determining

which of the socio-economic variables were included in the model, logistic regression

models were nui without any milk feeding variables. These models were created by building

a separate model for each socio-economic variable, and adding one variable at a tune until

39

one or more of the variables were no longer significantly associated with age of introduction.

There were no models with more than one independent variable. Thaefore, the results were

identical to the univariate regression models found in Table 24.

3.4.2 1992 survey

Data in Table 24 show that in univariate analysis of the m i k feeding at birth

variables, fonnula at birthmilk and breast at birth were significantly associated with age at

solid food introduction. Being formula fed at birth increased the likelihood of being given

early solids (OR=2.85,95%CI=1.52-5.29), while being breastfed at birth had a protective

effect (OR=0.44,950/CI=0.26-0.75). Breast milk at six months also had a protective effect

(OR=0.29,95%CI=O. 16-0.52). Infants were more likely to be introduced to solids before

four rnonths if they were formula fed at birth, and less likely if they were breastfed at birth

or continued to be breastfed at six rnonths.

With formula at birth entered as the fkst variable into the logistic regression model,

only education produced a model in which both variables were significantly associated with

age of introduction (model 6). This model is presented in Table 26. Receiving formula at

birth increased the likelihood of being introduced to solid foods before four months

(OR=2.15), while education had a protective effect (OR=0.69). Infants more likely to be

introduced to solids before four months were those who were formula fed at birth and whose

mothen were l e s educated. No M e r models were developed since the rest of the socio-

economic variables were not significantly associated with age of introduction. 'Formula at

birth? education' was chosen as the best model (model 6).

40

With breast at birth entered as the first variable into the logistic regression model,

only education produced a model in which both variables were significantly associated with

age of introduction (model 7) (Table 26). Breast at birth and education both had protective

effects (OR4.33 and 0.70 respectively), and therefore decreased the likelihood of early

solids. No M e r models were developed because the rest of socio-econornic variables were

not significantly associated with age of introduction. 'Breast at birth, education' was chosen

as the best model.

Data in Table 26 show that with breast milk at six months as the first variable

entered uito the model, education was the only variable to create a mode1 in which both

variables were significantly associated with solid food introduction. Infants less likely to

have received solid foods before four months were those who were still breastfed at six

months (OR=0.32), and whose mothers had a higher level of education (OR4.72). There

were no models with three variables, therefore 'breast rnik at six months, education' was

chosen as the best mode1 (mode1 8).

When nuining models without any rnilk feeding variables (as descnbed in the section

above), the (socio-economic) variables significantly associated with solid food introduction

did not differ fiom those models in which milk variables were included, i.e. education was

the only variable to be included in the model.

3.4.3 1996 survey

In univariate analysis, formula at birth, breast milk at birth and breast milk at six

months were all significantly associated with the age of solid food introduction. 'Ihese data

41

are presented in Table 24. Mants had a higher likelihood of receiving solids before four

months ifthey were formuia fed at birth (OR=5.18,95%CI=2.56-10.42); breast mik at birth

(OW.35, 95%CI=0.19-0.64) or at six months (OR4.23, 95%CI=0.09-0.51) had a

protective effect against early solids.

Logistic regression models were created by includhg formula at birth as the first

variable, and then by adding the other variables (excluding other milk feeding variables),

each to a separate model. Age, marital status, income, smoking while pregnant, smoking

after birth, and environmental tobacco smoke in the home (ETS) were significantly

associated (individually) with age of introduction, when formula at birth was in the model.

In developing models with formula at birth and two other variables, many potential models

existed, in which al1 three variables were signi ficantl y associated with age of introduction.

Further developing models with formula at birth and three other variables, the only model

in which al1 variables were significantly associated with age of introduction was 'formula

at bkth, age, ETS, support' (model 9) (Table 27). In this model, infants were more likely to

be given solids before four months if they were formula fed at birth (OR=3.96,95%CI=1.78-

8.77), were exposed to ETS at home (OR=4.18, 95%CI=2.15-8.23), and had a mother who

was younger (OR4.88, 95%CI=0.82-0.94) who did not receive support d e r birth

(OR=0.36,9S%CI=0.15-0.89). This was chosen as the best model.

Breast at birth was introduced as the first variable in the regression model, and then

the other variables were added (excluding other milk feeding variables), each to a separate

model. Age, marital status, education, income, smoking while pregnant, smoking after birth,

42

and environmentai tobacco smoke in the home (ETS) were significantly associated

(ïndividually) with age of introduction, when breast at birth was in the model. In developing

models with breast at birth and two other variables, three potential models existed, in which

al1 three variables were significantly associated with age of introduction. Shown in Table

27, the three models were 'breast at birth, age, income' (model 10)' 'breast at birth, age,

ETS' (model 1 1) and 'breast at biah, income, ETS' (rnodel 12). In these three models, breast

at birth, age, and income decreased the Ucelihood of solids being introduced before four

months of age, while ETS increased the likelihood. In models with breast at birth and three

other variables, none existed in which al1 of the variables were significantly associated with

age of introduction.

A simple regression showed that income was highly associated with age @<0.005)

and ETS (p<0.005). Age and ETS were also associated with each other @<0.05). The odds

ratios and confidence intervals in models 10, 1 1 and 12 did not indicate that the variables in

one of these models were more strongly associated with the age of solid food introduction

than the variables in one of the other two models. There was a larger percentage of missing

values for income compared to age, indicating that perhaps some women were uncornfortable

disclosing theV income. Since income was highly (inversely) associated with age and ETS,

model 11 'breast at birth, age, ETS' was chosen as the best model. In this model, infants

were less likely to be inûoduced to solids before four months if they were breastfed at birth

(OR=0.39,95%CI=0.20-0.73), had an older mother (OR=û.87,95%CH.8 1 -O.%), and were

not exposed to ETS at home (OR=4.07,95%CI=2.12-7.85).

43

In a logistic regression model with breast mik at six months as the first variable to

be included, age, marital status, education, income, smoking while pregnant, smoking after

birth, and ETS were sigdicantly associated (individually) with age of introduction. It was

decided to use ETS as the smoking variable, because this would include mothers who

smoked while pregnant, or &er birth, and it would also ensure that the sample size would

not be too small. In developing models with breast mik at six months and two other

variables, many potential models existed in which al1 three variables were significantly

associated with age of solid food introduction. In M e r developing models with breast milk

at six months and three other variables, two models had four variables in which dl were

significantly associated with age of introduction. These models are presented in Table 27.

In these two models, Sau t s were less likely to be introduced to solids before four months

if they (1) continued to be breastfed at six months (OR=0.32), were not exposed to ETS at

home (OR=4.36), and had an older mother (OR=0.88) who received support afier birth

(OR4.3 1) (model 13), or (2) continued to be breastfed at six months (OR=0.25), were not

exposed to ETS at home (OR=3.3 7), had a higher family income (OR=0.67), and a mother

who received support after birth (OR4.36) (model 14). Running models with breast mik

at six months and five other variables provided no models in which al1 variables were

significantly associated with age of introduction. Therefore, the best of the two previous

models with four variables was chosen.

breast miik at six months, support, ETS, age (model 13)

breast mik at six months, support, ETS, income (model 14)

44

Expianation for chooshg best modei: Models were nin with the variables 'breast mik

at six months, support, ETS, age, incorne' and 'breast mifk at six months, supporf ETS, age,

income, marital status, education' to see which variables would fali out of the models. In

both cases, the variables si@cantly associated with age of introduction were 'ETS, breast

milk at six months, support, age'. Suice age and incorne were highly associated @<0.005),

it was likely that age served as a proxy for income. It could be argued that the model which

best descnbes the relationship between solid food introduction and these independent

variables is model 14. However, due to the larger percentage of missing values for income

compared to age, it is clear that some women are uncornfortable disclosing their income.

niere is no reason to M e r stigmatize women in lower income brackets. Thus, when

targeting women for infant health prograrns, age may be a more successful method of

identifjing women likely to introduce solid foods before four months. Mode1 13 was

therefore chosen as the best model 'ETS, breast milk at six months, support, age'.

Logistic regression models were nin without any milk feeding variables (as

descnbed above). There were many models with two variables in which both were

significantly associated with age of introduction. in models with three variables, there were

four in which all three variables were significantly associated with age of introduction; they

are presented in Table 27. There were no models for which ali four variables had significant

associations with age of introduction. Therefore, of the four previous models, the best model

was chosen.

age, income, support (model 15)

ETS, marital status, support (model 16)

ETS, age, support (model 17)

education, support, marital status (model 18)

Explanation for choosing best model: Of these fou. models, three have variables for

which the confidence interval inciudes one (models 15, 16 & 18). Furthemore, a logistic

regression model was nin with 'support, ETS, age, income, marital status, education' to see

which variables would fa11 out of the model. The variables which were significantly

associated with solid food introduction were ETS, age, and support. These are the same

variables as in model 13 above, with breast rnilk at six months.

Income was highly associated (p<O.OOS) with age, education, marital status and ETS,

respectively. Because of the close relationship between age and income, and due to the

sensitivity in collecting a penon's income, model 15 should not be considered the best

model. Marital status was highly associated with ETS (p<0.05), education @<0.005), and

age @<0.005). Statistics Canada reports that older women are more likely to be mamied

[85]. If age was substituted for marital status in model 16, then model 17 is obtained. ETS

was significantly associated with age @<0.05), however support was not associated with

ETS (pX.05) nor age @>0.05). The relationship between ETS and age was not typical in

the sense that income was highly associated with both age and education. One would then

expect older people to smoke less. However, this does not seem to be the case in this cohort.

Mode1 17 therefore seems Wce a good choice for best model. Because education was

associated with marital stahis (older women are more likely to be married, and are also more

46

likely to have a higher education), mode1 18 should not be considered the best model.

Model 17 'ETS, age, support' was therefore considered to be the b a t choice.

1 Total 1461

Table 2 - The number and percentage of completed surveys, by year of study.

1 Completed 1 373

Sampling frame

1 Refusal rate 14%

1988

1 Not possible to reach 115%

Language problem

% total births in region during calendar year

NIA

4%

Table 3 - Percent distribution of al1 women aged 15 to 44 years by marital status, who had at least one child at the time of the 1991 Census of Canada (June 4,1991) (first three columns) and the percent distribution of al1 women in the 1988,1992 and 1996 Ottawa-

1 Includes common-law marriages.

Carleton surveys by marital status.

Marital status

,

Single

~ a r r i e d '

Separated

Widowed

Divorced

Canada (%) (n=3,499,780)

6.3

82.8

4.2

< 1

6.0

Ontario (%) (n=1,269,730)

5.4

83.4

4.8

< 1

5.6

Ottawa (7%) (n=83,480)

5.5

81.8

5.0

< 1

7.0

'88 cohort (%) (n=373)

4.0

94.6

1.1

O

< 1

'92 cohort (%) (n=330)

5.2

93.6

< I

O

< 1

'96 cohort (%) (n=338)

5.9

92.6

1.2

O

< 1

Table 4 - Percent distribution of al1 women by age who had at least one child at the time of the 1991 Census of Canada (June 4, 991) (first three (

Mother's age (Y cars)

hmns) and the percent distribution of al1 women in the 1988,1992 and 1996 Ottawa-Carleton surveys by ale I I 1 1

Canada (%) (n=3,499,780)

Ontario (%) Ottawa (%) <88 cohort (%) 1 <92 cohort (%) 1 <96 cohort (%) (n=1,269,730) (n=83,480) (n=373) (n=330) (n=338)

Table 5 - Percent distribution of ever-married women aged 15 to 44 years by highest level of education, who had at least one child at the time of the 1991 Census of Canada (June 4,1991) (first column) and the percent distribution of al1 women in the 1988,1992

1 s high school

and 1996 Ottawa-Carleton by bighest level of education.

( post-secondary non-university 1 28.1 1 27.3

Education level

1 some university 1 9.6 1 5.6 1 7.9 1 3.6

Canada (%) (n=3,499,780)

'88 cohort (%) (n=373)

university graduate 11.2 36.7 38.5 33.9

Table 6 - Percent distribution of infants according to the type of milk feeding at birtb, by year of study.

1 Missing (n) 10

Formula only

Breast and formula

' NIA = this question was not asked in 1988.

1996 (n=338)

65

1992 (n=33O)

65

Type of feeding at birth

Breast only

20

NIA'

1988 (n=373)

80

16

18

13

22

Table 7 - The mean and median age at first solid food, by year of study.

Mean age (monthksd)

Median age (month)

* Eleven of the 12 missing values represent babies who had not been introduced to solid foods by six months of age. Since their age at introduction is not known, the true rnean age of the cohort will be greater than the value calculated above.

The 30 missing values represent babies who had not been introduced to solid foods by six months of age. Siace their age at introduction is not known, the true mean age of the cohort will be greater than the value calculated above.

The 13 missing values represeot babies who had not been introduced to solid foods by six months of age. Since their age at introduction is not known, the true mean age of the cohort will be greater than the value calculated above.

1996 (n=338) 1988 (n=373)

missing (%)

1992 (n=330)

4.2' I 1.2

4

3'

4.0' k 0.8

4

4.1' I 1.3

4

92 43

Table 8 - Aee of infant at solid food introduction. bv vear of studv.

(mon ths) n YO c%' n %

1 7 2 2 - 6 2

' C % = cumulative percentage

Table 9 - Percent distribution of infants by age at solid food introduction, according to

Age (months)

1 Total

feeding method (%) I

breast I formula (n=300) (n=72)

ar of study.

1992 feeding method (%)

I I

breast 1 formula 1 both '

1996 feeding method (%)

' both = breast and formula

BF = milk feeding is exclusively breast milk BF&FF = milk feeding is breast milk supplernented witb formula FF = milk feeding is only formula

Milk feeding method 1988

Table lob - Percentage of infants introduced to solid foods before 4 months of age according to tbeir milk feeding method at six months of age.

1 I I

I

Cow's 34 73 71 7 58 12

BF = milk feeding is exclusively breast milk BF&FF = milk feeding is breast milk supplemented with formula FF = milk feeding is only formula Cow's = milk feeding is only cow's milk

Table 11 - Percent distribution of infants by age at solid food introduction according to the type of milk feeding at 6 months, for the 1988 cohort. I I I

1 1 Total ?40

Age in months

1

2

Feedine method (241 1

breast only' (n=72)

O

O

At 6 months of age: ' Breast only = milk feeding consisted exclusively of breast milk ' Breast & formula = milk feeding consisted of breast milk and formula supplements ' Formula only = milk feeding consisted exclusively of formula ' Cow's milk = milk feeding consisted only of cow's milk

breast & formula2 (n=46) formula onlg (n=l78) cow's milk4 (n=73)

œ œ 3

E (I

s O z -

h -

cri -

Ir 7

L -

Li -

cri -

rri

f L z Y Q ol c z -

b=breast f= formula fed

Variable

Feeding at birth

Solid introduced

Mother's age

Mother9s education

Mother has partner

Smoked - pregnancy?

Mother smoked after birth?

ETS exposure in home

Total family income

I Parity s hs=s high school sps=some post secondary cg=college grad univ/+=university or higber

b

6

26

SPS

no

no

yes

Yes

<$20k

I 2

f

3

27

SPS

Yes

Yes

Yes

Yes

r $60k

1 1

both

1

29

Cg

Yes

no

no

no

r $60k

I 1

f

3

17

c; bs

Yes

no

Yes

Y es

4 2 0 k

I f

b

4

33

c; hs

Yes

no

no

Yes

<$20k

I 3

b

3

24

Cg

Yes

no

no

no

<$20k

I 1

b

1

37

un iv/+

Yes

no

no

no

r $60k

I 3 I

Table 15 continued. Profile of babies introduced to cow's milk by 6 months, in

i 1

996 cohort,

Variable 1 1 Feeding at birth both 67% breas t

17% formula 17% both

Solid in troduced 13 12 3.4 months

Mother's age 1 a?i 27 years -

Mother's education 42Y0 s hs 25% sps 25% cg 8% univl+

Mother bas partner 1 no 1 Yes 83% yes

Smoked - pregnant 1 Yes 1 no 25% yes

Smoked after birth 42% yes

Variable

ETS exposure in borne

Total family income

Parity b=breast at birth sps=some post secondary education f= formula at birth cg-college grad 5 hs=s high school education

50% ETS

1.6 children

Table 17 - Percent distribution of infants according to the type of food they were first piveo, by year of study.

First solid food

Cereal

Vegetable

Fruit

Not yet introduced

Missing

% 1988 (n=373)

94

< 1

2

4

< 1

% 1992 (n=330)

89

1

1

9

O

% 1996 (0=338)

92

3

1

4

O

Age in rnonths (row %)

Type of food 1 1 2 1 3 4 1 5 16 1 > 6

1988 (n=373)

cereal (n=350) 2 4 16 39 27 11 4% of total sarnple

vegetable (n=2) - - - - 50 50

fruits (n=7) - - 14 29 43 14

cereal (n=294) 2 4 18 58 17 < 1 9% of total sample

vegetable (n=2) - - - - 100 - fruit (n=4) - - 50 50 -

- -

1996 (n=338)

cereal (n=310) 1 7 9 47 26 1 1 4% of total sample

vegetable (n=ll) - - 18 55 9 18

fruit (n4) - 25 25 - 50 1

All itdicized values represent percentages of very small sample sizes (i.e., n=l, 2 or 3).

Table 19 - Percent distribution of infants according to the different types of food they have been fed by 6 rnonths of age, by milk feeding method at birth and 6 months, for the 1996 cohort.

Total s a m ~ l e sue = 338.

Types of food 6 months (%) birth (%)

cereal 1 61 1 21

veeetables

fruit

meat

other grain

other milk product

eggs

other

Rows may not add to 100%. as not al1 infants bave been introduced to al1 types of food. other grain = cookies, biscuit in camomile, baby cookies, crackers, pasta, chinese noodles,

bread, bread sticks, rice. other milk product = ice cream, yogurt, cottage cheese, custard. other = mixed food, camomile tea.

Table 20 - Percent distribution of infants by age according to the diiferent types of food hey have been fed by six months of age, in the 1996 cohort. Total sample size = 338.

Age in months (%)

Types of food I l l 2 l 3 cereal I I I O I S

mea t I - 1 - I -

vegetable

fruit

< 1

-

other grain

other milk product

egss

other

Rows may not add to 100%, as not al1 infants have been introduced to al1 types of food. other grain = cookies, biscuit dissolved in carnornile, baby cookies, crackers, pasta,

chinese noodles, bread, bread sticks, rice. other milk product = ice cream, yogurt, cottage cheese, custard. other = mixed food, carnomile tea.

6

14

7

> 6

4% of total sample 2

-

- - - -

3

2

- - -

< 1

< 1

69

Table 21 - Materna1 and mllk feeding characteristics in relation to the introduction of solid foods at 4 and 24 mc mths of age, by ye r of study ( X tests).

Age at solids introduction (% total) Characteristic

- - - - - -- - -

Feeding at birth breast formula breast & formula

Mik feeding at 6 mos breastmilk formula cow's milk ('88 only) 1

Mother's age < 23 23-29 r 30

Marital status no partner partner

Education s high school some post-secondary colïege graduate r university graduate

Famiiy incorne < 20,000 20,000-29,999 30,000-49,999 ('92&'96) r 50,000 (S30K in '88)

Mother9s parity 1 child 2 children r 3 children

' COW'S mi.Uc is includeù in the chisquare test for 1988 only. The niimber of children given cowys milk in 1992 and 1996 was too small to inclade them in the chi-square test These chiidren have been described in Tables 14 & 15. The significance level equals 0.005.

Mother received helpladvice occasionally(no - '92,

'96) often &es - '92, '96)

Significance: The sipificance level represents a cornparison between the introduction of soüd foods at < four months, and z four months of age and the categories of the listed characteristics.

bl border Une (>0.05-0.1) * s 0.05 ** <O.Ol *** <0.005

58 313

19 310

37 301

17 22

83 78

23 16

77 84

bl 27 15

73 85

Table 22 - Smoking and ETS in relation to the introduction of soiid foods 4 and 24

Characteristic

months of a e, b ear of stud X * tests

r-7- Mother smoked while pregnant yes ' no

Mother smoked after birth yes ' no

Exposure to ETS at home yes no

Age at soiids introduction (%total)

Signficance: The significance level represents a comparison between the introduction of solid foods at c four months, and r four months of age and the categories of the listed characteristics.

bl border line (>0.05-0.1) * s 0.05 ** <0.01 *** <0.005

Table 23 - A cornparison of mother's (n=363) and father9s (n=10) responses,

- - -

Father's response Variable

Soüds introduced < 4 months r 4 months

Birth breast formula

Breastfed at 6 mos yes no

Mother's age 4 3 y r ~ 23-29 yrs > 2 9 p

Marital status partner no partner

Mother smoking yes no

ETS in home Yes no

- -- -

Income 4 2 0 K $20 - 29K > $30K

Education s high school some post-secondary eollege grad university +

Support occasionaiiy often

Table 24 - Materna1 and infant characteristics associated with the likelihood of solids being introduced before 4 months, by year of study.

Characteristic Univariate odds ratio (95% confidence interval)

Milk feeding variables 1988 1992 1996

breast fed at birth

formula fed at birth

breast and formula fed at birth 1 - 1 1.18 (0.60-2.23) ( 1.02 (0.49-2.01)

breast fed at 6 months 0.37 (O. 19-0.68) 1 0.29 (0.16-0.52) 1 0.23 (0.09-0.51)

formula fed at 6 months -- -

cow's milk at 6 months

Mother9s characteristics

marital status

education

family income

mother received support/help alter birth 1 1.33 (0.66-2.92) 1 1.61 (0.52-7.07) 1 0.46 (0.21-1.06)

Table 25 - Selected characteristics associated with the introduction of solid foods before 4 months after adjustment for other variables for the 1988 cohort.

1 1 Adjusted odds ratio (95% confidence in terval) 1

1 cow's milk at 6 months 1 1 1 1 2.00 (1 .09-3.61) 1 2.1 1 (1.1 6-3.78) 1

Characteristics

breast fed at 6 months

1 rnother's age 1 1 0.94 (0.88-1.00) 1 1 ( 0.94 (0.88-1 .OO) 1

mode1 1

0.45 (0.22-0.89)

rnother's education

marital status

mode1 2

0.43 (0.21-0.80)

0.76 (0.61-0.94)

mode13

0.37 (0.19-0.69)

0.38 (0.1 5-1.01)

mode14

0.76 (0.61 -0.94)

mode1 5

Table 26 - Selected characteristics associated with the introduction of solid foods before 4 nonths after adjustment for other variables for the 1992 cohort.

Characteristics

breast fed at birth

formula fed at birth

breast fed at 6 months

mother9s age

mother's education

family incorne

ETS 1 1 1

Adjusted odds ratio (95% confidence interval)

mode1 6

2.15 (1.11-4.12)

0.69 (0.55-0.87)

mode1 7

0.33 (0.15-0.72)

0.70 (0.50-0.96)

madel 8

0.32 (O. 1 7-0.58)

0.72 (0.57-0.91)

Table 27 continued

Adjusted odds ratio (95% confidence interval)

1 Characteristics 1 mode115 1 mode116 1 mode117 1 mode118 1 1 mother9s age 1 0.89 (0.82-0.96) 1 1 0.86 (0.80-0.92) 1 1 1 mother9s education 1 family income

marital status

received support / help after birth

ETS

0.66 (0.48-0.91)

0.40 (0.1 7-1.02)

0.37 (0.15-0.98)

0.42 (0.1 8-1.01)

4.53 (2.42-8.53)

0.35 (0.1 5-0.86)

4.38 (2.30-8.43)

0.39 (0.16-1.01)

0.4 1 (O. 19-0.97)

.

L a c t e r i s tic --.

1 Adjusted odds ratio (95% confidence interval)

bthether smoked wbile prognant

F m o k e d after birth

NI = not included

ETS exposure at home 1 .O8 (0.49-2.29) 0.36 (0.06-1.38) 3.81 (1 .40-10.24)

4. Discussion

The objectives of this study were to descnie infant feedùig practices during the first

six months of life, focusing on the introduction of solid foods, and to examine socio-

demographic characteristics and breastfeeding practices of infants' mothers who tended to

introduce solids before four months of age. Three surveys conducted by the Ottawa-Carleton

Health Department over ten years provided the data upon which these analyses are based.

It is not surprising that ten years ago, it was not foreseen that these three surveys would be

conducted, and their data compared. Although the surveys' objectives are not identical

(Appendix 4), infant feeding is a comrnon theme throughout .

4.1 Interpretation of results in view of CPS guidelines

The descriptive data illustrate that the majority of infants were introduced to solid

foods at four months. While at first glance this might appear to be acceptable, a closer look

reveals that many mothen are not folIowing the CPS guidelines where solid food is

concerneci. The guidelines state that solids should normally be introduced between four and

six months, according to the developmental readiness of the infant [30]. If this

recommendation was being followed, the distribution for solid food introduction would not

have a peak at four months. Rather, the median would be greater than four months, and the

entire curve would be skewed to the lefi. The fact that the majority of infants had been given

solids by their fourth month indicates that developmental cues were not likely taken into

account. A plausible explanation is that at the infant's four month medical checkup, the

82

physician may indicate that it is now time to introduce solid foods; the mother obliges. It is

therefore recommended that mothers, or the primary caregiver (if someone other than the

rnother) be encouraged to watch for signs that the infant is ready for solid foods, rather than

using a specific age as the deciding factor. It is also recommended that mothers be r e a s d

that until six months of age, their infants can receive adequate nourishment fiom breastmilk

(andor formula) alone.

For each cohort, the descriptive, univariate and multivariate analyses al1 reported that

'new' rnothers who have chosen not to breastfeed, or have stopped breastfeeding shortly after

birth were most likely to introduce early solids. Iiifants were more likely of having received

solids before four months if they were being fed cow's mik at six months, compared with

breastmilk at six months. In summary, the kind of milk infants receive at bkth and at six

months plays an important role in predicting early solid food introduction.

The data indicate that only a maIl percentage of mothers are continuhg to breastfeed

their infants until six months of age. Aimost a third of the infants breastfed at birth

continued to receive breastmilk at six months. The CPS recommends that mothers breastfeed

exclusively for four months, and then continue to do so for up to two years of age or beyond

[30]. It is therefore recommended that mothers be encouraged to breastfeed their children

for much longer than they currently do. Issues swounding breastfeeding are discussed in

Section 4.6.

The dmp in cow's milk use is welcomed. This drop is likely due to cornpliance with

83

the 1 99 1 CPS recommendations which stressed the importance of iron in the child's diet, and

recommended that cow's milk should not be given until an adequate amount of solid food

containing iron and vitarnin C is included in the diet, preferably at nine to 12 months of age

[34]. The first solid food was usually cereai and the order of subsequent solid foods is as

recomrnended by the CPS.

Despite these generaluations, there was not a consistent pattern throughout the three

cohorts as to which variable was most indicative of solid food introduction before four

months. From a practical point of view it is not very useful laiowing that a six month old

infii~lt who is breastfed was not likely to be given solids when he was four months 016

However, it is possible to act on the knowledge that infants who are formula fed at birth are

more Likely to be introduced to solids before four months. Once it is known by a physician

or public health nurse that a mother is formula feeding shortly d e r b i a it is possible to talk

with her about the proper t h e to introduce solid foods, and the reasons for delaying solids

until that time. Lf a mother has initiated breastfeeding and continues to do shortly d e r birth,

then the emphasis should be placed on breastfeeding support. Taken together, these resdts

support the recornmendation that it is necessary for health professionals to identify women

who do not breastfeed or stop doing so shortly after birth, and to ensure that these mothers

are aware of the CPS guidelines regarding solid food introduction. Strategies should be

developed to ensure that al1 health professionals are giving a positive and consistent message

regarding breastfeeding and the introduction of solid foods.

4.2 Cornparison of the descriptive results with the Canadian literahire

Compared with other regions in Canada, resdts h m this study indicate that the

percentage of infants introduced to solid foods at the appropriate age is increasing. However,

when cornparing this study's results with those of an Ottawa-Carleton cohort sampled in

1984, it does not appear that there has been as much progress.

Greene-Finestone [22] reported a mean and a median of 4.3 and 4.0 months,

respectively. These values do not Vary considerably fiom those reported in this study. It is

interesting to note that although the mean and median values are similar, there are some

slight differences in the distribution of solid food on a month by month basis. Greene-

Finestone reported the cumulative percentage of infants given solid food at the following

ages: 8.8% (one mont.), 14.1% (two), 33.8% (three), 56.6% (four), 72.2 (five) and 93.1 (six).

Comparing this distribution with those fkom the 1988, 1992 and 1996 cohorts, a greater

percentage of the Greene-Finestone infants were introduced to solids at one, two, and three

months, and a smaller percentage at fou., five, and six months. This indicates that although

the mean and media. values have not changed, a çmaller percentage of infants in the current

shidy were introduced to solid foods before four months of age. This is a step in the right

direction. There have not been any public health initiatives specific to the Ottawa-Carleton

region in the past decade to explain these changes [85].

When this study's results are compared with similar studies in Canada during the

1990s, it is evident that in generd there is an increase in the percentage of infants introduced

85

to sotid foods at the appropriate age. The mean age of introduction in the present study was

p a t e r than those reported in two Québec studies (3 1% of infants introduced to solids < two

months; cereal given to most infants by 3.5 months) [25-261, in a Hamilton cohort (rnost

infantç introduced to solids c four months) [24], and in a Sudbury cohort (32% of infants

introduced to solids at three months) [27], and less than those in a Vancouver cohort (most

infants given solids > four months) [23]. The percentage of infants on solids at four rnonths,

according to milk feeding at birth (breast or formula) was sirnilar to results from

Newfoundland and Labrador (63% breastfed and 78% boale fed babies on solids at four

months) [70] (see Appendix 1 for more detail).

4.3 Cornparison of the analytical results with the international literature

This study is the fïrst in Canada to attempt to examine the effect of socio-

demographic variables and breastfeeding history on the introduction of solid foods. It is also

the fim time in Canada in which age, marital status, incorne, support and exposure to smoke

(mother smoking during pregnancy, after birth, and ETS) have been reported to be

(univariately) associated with the age of solid food introduction. A significant association

of these variables with breastfeeding, however, is well established [68, 86-87].

Some of the univariate results in this study correspond with the Canadian literature.

The association between a Iack of breastfeeding at birth, or at six rnonths, with the

introduction of solids before four mon& is consistent with al1 of the Canadian studies

(Appendix 1). Socio-economic status (SES) and education have been reported to be

86

inversely related with early solids introduction [16, 19,22,25]. Although SES per se was

not measured in the current study, a higher family income was statistically associated with

solid introduction at or d e r four months of age.

These univariate results are also in agreement with international studies, including

the United States, the Netherlands, France, Britain, S weden, Australia, and New Zealand.

Significant associations between early solid introduction and variables such as no or

decreased breastfeeding, maternal smoking, and lower maternal education have been reported

[88-951.

The use of logistic regression allowed for the control of explanatory variables. The

results of the multivariate analysis indicate that milk feeding at birth, or six months plays an

important role in predicting if an infant will be (or will have been) introduced to solids at the

appropriate age. Other variables such as education (1 988, 1 %2), ETS (1 996), income

(1996), age (1996) and support (1996) appeared in the final models. For the 1996 data, an

attempt was made to choose the best model; a comparison of these models with those fiom

previous studies may help to confirm the choices made in Section 3.4.3.

Most infant feeding studies to date have not assessed the effiect of socio-demographic

factors or breastfeeding history on the introduction of solid foods. In fact, none of the

Canadian literature, and only a small number of studies from other developed countries

controlled for explanatory variables. Through the use of multivariate regression, not

breastfeeding at four weeks, a low level of maternal education and heavy matemal smoking

87

were associated with early solids introduction [95]. Amongst low-income women, the best

predictor of the duration of breastfeeding was the age of the infant at the tune of introduction

of solid foods [96]. Therefore, these results stress the importance of breastfeeding with

respect to solid food introduction. It is essential to continue to encourage rnothen to

exclusively breastfeed their infants for the first four rnonths of life, and to continue

breastfeeding, even after solids have been introduced. This is precisely what the CPS

guidelines recommend [3 O].

The results nom these two studia [95-961 emphasize the association of breastfeeding

and education with solid food introduction. The presence of smoking in Ford's [95] study

lends support for having ETS included in the best model (1996). As discussed in Section

3.4, ETS was associated with both income and age, although its association with income was

not as strong as with age. Given the sensitivity of disclosing family incorne, and the larger

percentage of women who refused to disclose their income in this study, age may be a more

successful variable in identifjmg women likely to introduce early solids. This rationale

M e r supports choosing the model which includes ETS, age and support.

From these results it is recommended that breastfeeding and support issues be

addressed for expecting mothers and their partners. Given the complexity surrounding these

issues, a population health perspective should be used. This will help ensure that the many

different factors that determine health are addressed. For example, such an approach would

take factors such as education, social support networks, and personal health practices into

88

consideration. Because many institutions are operating on very low budgets, particular

attention should be given to developing programs for rnothen that are least Likely to follow

the CPS guidelines. These initiatives should therefore focus on mothers who are younger

and less educated, and who are smokers or whose partner smokes.

4.4 Soci+economic variables and early soüd food introduction: What is the Cbnnection?

4.4.1 Edacation and age

Younger and less educated mothers have a greater likelihood of giving solid foods

to their infants before they are four months old when compared with mothers who are older

and more educated. This relationship can Uely be explained through the following

rationale. Older mothers tend to be more educated [84]. Many women postpone having

children in order to pursue a higher education. When these wornen do have children, they

are likely to be better established in that they are more financially secure, have more self-

confidence, are more resourceful, and are more mentally prepared to embark into

motherhood. Mothers with a higher education may also be more 'information hungry' and

are therefore more aware of infant feeding guidelines. These factors can play an enormous

role in allowing a mother to provide the best possible environment for her child.

4.4.2 Social support

A mother is more likely to breastfeed successfully and for longer, if she receives

support fiom her partner, family, fnends and breastfeeding support groups [97-991. Of

course, support fiom society in general would no doubt make breastfeeding more acceptable,

but as described in Section 4.6 this is a complex issue.

4.4.3 Environmentai tobacco smoke

In this study, the presence of ETS in the home was associated with matemal smoking

both during pregnancy, and after birth. The relationship between tobacco smoke and early

solid food introduction raises some interesting questions. 1s this association biologically

plausible? Perhaps the passive inhalation of moke, or the ingestion of its metabolites f?om

breastmilk have an effêct on the child's behaviour causing fussiness, which prompts parents

to give solids at an early age. Another possibility is that smoking itself inhibits the

breasonillc supply, leading to cessation of nursing. A lack of breastfeeding is strongly Iinked

with early solid introduction. Finally, a non-biological explmation is that mothers find

smoking and breastfeeding to be a contradiction of ternis. A mother who breastfeeds wants

to provide the best possible environment for her child, and is therefore not as Iikely to smoke.

Or perhaps smoking represents a lack of awareness regarding health issues.

Women who smoke tend to wean their babies earlier than non-smokers [100-1021.

The earlier cessation of breastfeeding may be par?ially explained by a nicotine-induced

reduction of prolactin [ 103- 1051. Weitzman reported an independent relationship between

materna1 smoking both auring and alter pregnancy and increased rates of behaviour problems

of children, with evidence suggesting a dose-response relationship [106]. An increased

incidence of lower respiratory-tract Sections, asthma and middle ear infections have been

reported in children exposed to ETS [107-1101. Behavioural problems and illness rnay be

90

misinterpreted as fussiness, leading the parents to give solids in an atternpt to calm their

child. Taken together, these studies suggest hypotheses for the earlier introduction of solid

foods in children exposed to passive and prenatal tobacco srnoke.

4.5 Study strengths and limitations

The strengths of this study include a large sample size which enabled the examination

of effects of various sociodemographic factors and breastfeeduig history on the introduction

of solid foods, and the oppominity to study infant feeding trends over the course of a decade.

Praious Canadian shidies did not employ rnultivariate analysis, which makes it impossible

to control for certain variables which are clearly related.

The limitations relate to a lack of information in several areas. There were no data

on maternity leave or ethnicity/culture. Nor were there any qualitative data as to why

mothers introduced solids when they did.

A prospective cohort design would have provided a more complete data set on the

type of milk the infant was receivuig at various points in time rather than only at birth, and

at six months. However, given the hancial constraints and the potential loss to follow-up,

the current study design was employed. Non-response b i s , and recall bias were also

concems. It is possible that the mother did not accurately remernber when solid food was

introduced. However, Persson reported good validity of retrospective infant feeding patterns

obtained at six months of age [Ill] . Despite the hi& response rate, it would have been

desirable to determine if there was any response bias. However, this was not possible

91

because no idormation was collected fiom the mothers who refused to participate, and no

information was available fkom the mothers who could not be contacted.

Finally, it m u t be recognized that there are many different approaches to building

multivariate modelling, and that the models described in Section 3.4 are a product of the

modelhg procedure chosen for this analysis. Regardess of the modelling technique, when

more than one independent variable is included in a model, it will be more difficult to

determine the best choice of model, since there will sornetirnes be several reasonable

candidates fiom which to choose. In addition, it will sometimes be more difficult to interpret

what the best-fitting model means in real-life tems [112]. This study was exploratory in

nature, in that this was the 6rst time that such a study had been conducted in Canada. As

such, the modelling results should be interpreted with caution, and it is recommended that

m e r studies of this nature be conducted on the Canadian population in order to duplicate

this shidy's results.

It appears that the marital status and age of the mothers in this survey reflect those

of mothers in Ottawa, Ontario and Canada. The same cannot be said for education level.

Given the importance of education as a predictor of age of solid food introduction, the results

of this study rnay not be totally representative of al1 Canadian mothers, but likely provide a

very good indication. The prevalence of early solids introduction may have been under-

estimated given the higher education level in Ottawa, resulting in a bias towards the nul1

hypothesis. Because mothers in Ottawa tend to have a higher education level when

92

compared with Canada as a whole, education could potentially have a greater impact if these

results were to be extended to al1 Canadian mothers,

Maternal employment after childbirth plays a role in breastfeeding duration, but not

in breastfeeding initiation. Studies of American women have f o n d that planning to be

employed d e r childbirth did not make a ciifference in the mother's decision to initiate

breastfeeding [87, 1 131. However, women breastfed for a significantly shorter period of time

if they retumed to work within six months [113] or a year [87] afler deiivery. White

professional women were the most likely to breastfeed after retuming to work and had the

longest duration of nursing, despite having a matemity leave as short, or shorter than other

employed women [87]. Gielen [Il31 reported that arnong women employed outside the

home, those who were working 20 hours or less per week continued to breastfeed at a

significantly higher rate than women working more than 20 hours per week. In

Newfoundland and Labrador, only 8% of mothen who chose not to breastfeed gave work as

the reason; one third cited embarrasment or distaste [70]. These studies indicate that

although matemity leave can play a role in the duration of breastfeeding, it does not

influence the decision to initiate breastfeeding. Factors such as education and type of

emplo yment are O ften better predictors of a breastfeeding mother.

Ethnicity was not included in the analysis. Although the country of the mother's

birth was collected, the categories were not consistent for each of the three surveys. In

addition, there were many countries from which only one mother had emigrated, thereby

93

making the sample size too small to include in the analysis. Furthermore, a person's country

of biah and ethnicity are not synonymous. In the United States, significantly diffeient Sinfant

feeding practices regarding the introduction of solid foods were reported in mothen of

various ethnic backgrounds [114, 1 151.

The beliefs and practices underlying breastfeeding in Canada were recently describeci

[116]. A variety of culhiral communities was selected based on the rnost current

immigration trends over the part five years and projected patterns of immigration. Through

key informant interviews and a literature review, the document revealed the vast differences

in beliefs and practices of breastfeeding between cultures. It aiso found increased

breastfeeding rates in women of higher education and income levels, regardless of their

cultural background, indicating that some factors may override the influence of ethnicity .

These studies emphasize the need to include ethnicity in hture research, in order to

detemüne what influence, if any, it has on infant feeding practices.

Finally, this study did not include any qualitative data as to why solid food was

introduced at the given the . This type of information is necessary in order to get an in-

depth understanding of how personai and socio-economic and cultural factors interact, and

how they shape behaviour. It is recornmended that qualitative data be collected in the future.

Furthermore, demographic risk factors are often difficult if not impossible to modiQ

whereas having an impact on a person's knowledge or behaviour may be much more

feasible.

94

4.6 Low SES, lack of breastfeeding and early solid food introduction: What are the

potential reasons for this relationship?

The results of this study indicate that women with less education are more likely to

introduce solid foods earlier than recommended. Women of lower SES are dso less likely

to breastfeed their infants. These kinds of associations have been consistently reported

throughout the world fiterature. There is a lack of literature on solid food introduction and

an abundance of information on breastfeeding. Since early soIids introduction is so closely

related with the absence of breastfeeding, this next section will focus on breastfeeding in

order to investigate why women with certain characteristics tend to introduce solid foods

earlier than recommended.

In an attempt to increase breastfeeding rates, and thus lower the number of uifants

fed early solids, it is not helpfùl to target this group of "uneducated" women. It is not

appropriate (for a study such as this one) to simply state that if only these women were more

educated, they would breastfeed their children. Blarning the victim is not only unfair, but

it will never help to increase breastfeeding rates. A look into the issues surrounding

breastfeeding, or lack thereo f, is warranted.

In her book The Politics of Breastfeeding, Gabrielle Palmer [117] asks: Why is it t h t

whether you were breustfd yourselfor whether you breostfeed your own child depends so

much on your social and economic class position in your own society? Why is the right to

breastfeed fought for so vehemently by some women and rejected so forcefully by others

95

according to their class. educntion und society? The answer to these questions is complex

in that a number of factors have created a culture in which breastfeeding is not considered

the normal way for women to feed their children. People are not accustomed to seekg

nursing mothers and they do not consider breastfeeding to be a regular everyday activity.

A bottle and a baby are seen as natural partners [118].

Palmer argues that while social class plays an important role in infant ffeedig choice,

the use of the word 'choice' is not redly appropriate. In the past, many women bottle fed

their children, not because they chose to, but because the idea of feeding their children in any

other way did not aise or was not encouraged; this cultural nom still occurs today. In many

Westem societies, very few people leam how to breastfeed. Families are more dispersed,

and the art of breastfeeding is not learned within the family home. Through o b s e ~ n g

breastfeeding as an everyday activity, techniques are learned unconsciously at an early age.

Breastfeeding has suffered due to a loss of exposure, visibility, and support. For those

women who do breastfeed, it is usually done behind closed doors, and is subsequently

restricted by social mores and pressures to return to the workplace. The decision to

breastfeed, which may involve hom of reading for the fonnally educated women, is not part

of many women's lives.

This cultural context of breastfeeding is shaped by several assumptions about breasts:

the primary purpose of breasts is for sex and not feeding children (In many Western

societies, breasts are associated with sex. Women in Westem societies rnay decide not to

96

breastfeed because of inhibitions related to the cornmon perception of breasts as sexual

objects.); breastfieeding serves ody a nutritional fiinction (There are many additional b d t s

to breastfeeding including the development of the infant's immune systern, reducing the risk

of SIDS, and building a close infant-mother bond.); breastfeeding should be limited to very

young infants; and breastfeeding is appropriate only when done in private, and thereby is not

appropriate at work or in public places [119]. This 'culture of misùiformation' can begh to

be addressed by proviciing, to everyone concerneci, accurate, current information about the

advantages to women and children of choosing to breastfeed. Cultural perceptions have

tumed a natural biological process into something alrnost unrecognizable.

Factors which have created this attitude towards breastfeeding include

industriaiization and urbanization, the promotion of S a n t formula by manufacturers and

their relationship with medical doctors, the medicalization of childbirth, and cultures in

which sex is linked with breastfeeding. When comparing women of the same social class,

women in one society choose to breastfeed while those in another society refuse to do so

[117]. Palmer found that the breastfeeding women in both societies had access to good

information and support, either fiom fiiends and relatives or fiom breastfeeding support

groups and books.

Factories created a separate location for work and family. If a woman worked outside

of the home, which in many cases was the only option, this had a profound effect on her

ability to stay at home and breastfeed after birth. Motherhood became something that was

97

hked to the home environment. In this way, rnothers tended to be alone with their babies,

and lacked the encouragement and nurture to establish and maintain lactation. Women's

roles as mothers and wives were of Little concem to the employer. Both of these attitudes

have changed very little today. Women who work and want to breastfeed often face

obstacles upon Uitegrating the two [120]. Moreover, paid matemity leave and nursing breaks

are not offered to al1 women. AIlowing a mother this time with her child should not be

viewed as a favour; rather it is an investment in the health outcomes of children and

consequently an investment in the &hue.

The commercialization of infant fonnula and this industry's relationship with the

medical profession has convinced many mothers to bottle-feed, and consequently, to lose

confidence in their own mik and their ability to breastfeed. Women may ask themselves,

"why use my own milk when 1 can buy it?" Some Canadian women who chose to formula

feed felt that it was a social statement, suggesting that they could afford to feed their baby

[121]. In order for breastfeeding to be successfûl, women need to have confidence in the

breastmilk their own bodies produce, as opposed to formula produced by manufacturers.

It is also noteworthy to mention that a significant proportion of medicai and

nutritional research is hanced by the formula industry. It is difficult to measure the effect

that this hding source has on physicians' and nutritionistst attitudes towards breas tfeeding,

but anecdotal sources indicate that recipients of h d i n g from industry tend to be influenced

by their corporate dollars [ 1221.

98

Canada is a signatory to the WHO International Code of Marketing of Breast-mik

Substitutes, which works towards enniring thnt thme are no donations o f f ee or subsidized

supplies of breast-milk substitutes or any other products in any part of the health care

system. Despite Canada's cornmitment, fkee cases of infant formula are distrïbuted to

expecting mothers through their phy sicians' obstetric offices [ 1 231. There is direct

advertising and sample distribution to women individually and in prenatal classes.

Practices associated with hospital childbirth have had a negative impact on

breastfeeding practices. This was due to a number of factors, including the use of baby

nurseries which made it difficult for mothers to nurse on demand, the distribution of fke gifi

packs containhg formula, and because doctors themselves were not knowledgeable on the

practicalities of breastfeeding [I 17, 1 181.

A review of Canadian maternity hospitals' cornpliance with the WHO/UNICEF 10

Steps to Successful Breastfeeding found that only 4.6% of hospitals met al1 10 steps [124].

This figure dropped to 1.3% when the WHO International Code of Marketing of Breast-milk

Substitutes (WHO code) was added. Aithough some of the WHO steps were followed by

nearly al1 of the hospitals, for example, encouraging breastfeeding on demand, and helping

mothers to initiate breastfeeding within half an hour after birth, there were many steps which

were not followed. Almost half of the hospitals reported that breastfed babies received other

liquids (i.e., water, glucose, formula), and 40% reported not having a policy of o f f e ~ g

mothers information on breastfeeding support groups, or advice on breastfeeding at

99

discharge. In cornpliance with the WHO code, 60% of hospitals never gave see formula

samples to breastfeeding mothers and 30% never gave them to formula feeding mothers.

These latter practices clearly hinder the successful establishment of breastfeeding.

A study conducted in urban British Columbia reported that recent medical graduates

did not have a greater level of bredeedùlg counseling than did physicians trained in a time

less supportive of breastf'eeding [125]. Many American health care professionals do not have

adequate lactation Craining [98, 1 181. This clearly indicates that medical students are not

receiving adequate breasdeeding t 6 g .

4.7 The successful promotion of breastfeeding

Clearly, the decision to breastfeed, and by way of association, of when to introduce

solid foods is a complex subject. Many of the factors which contributed to the decline of

breaçtfeeding cannot be escaped, nor c m they be reversed. However, it is clear that in order

for breastfeeding promotion to be successfûl, the cultural perceptions cannot be ignored; nor

c m the 'culture of misinformation'. These two phenornena are reinforcing one another, and

are M e r accentuated by the relationship between industry and health professionals, thereby

creating a message in which the advantages of breastfeeding have become obscured. Instead,

the public receives a message that fdsely equates breastmilk with formula.

The Innocenti Dedaration on the Protection, Promotion and Support of

Breastfeeding [126] declares the necessary steps which must occur for breastfeeding to be

successful. They include an environment of awareness and support, an increase in women's

100

confidence in their ability to breastfeed and the elimination of obstacles within the heaith

system, the workplace, and the community.

4.8 Summary of recommendations

This section provides a summary of the recommendations which have corne out of

this study. Their goal is to Increase the number of infants introduced to solid foods at an age

appropriate time, when infants are developmentally ready.

It is recommended that breastfeeding and support issues be addressed for expecting

mothen and their partners. In order to make the best use of Limited resources, these

initiatives should be targeted at mothers who are younger, Iess educated and are

smokers. Given the complexity surroundhg these issues, a population health

perspective should be used to help ensure that the many different factors of one's life

are addressed.

It is necessary for health professionals to identifi women who do not breastfeed or

stop doing so shortly d e r birth, and to ensure that these mothers are aware of the

CPS guidelines regarding solid food introduction.

It is recommended that sû-ategies be developed to ensure that dl health professionals

are giving a positive and consistent message regarding breastfeeding, and solid food

introduction.

It is recommended that health professionais encourage mothers, or the prirnary

caregiver to watch for signs that the infant is ready for solid foods, rather than using

a specific age as the deciciing factor.

(5) It is essential to continue to encourage mothers to exclusively b r d e e d their infants

for the f k t four months of life, and to continue breastfeeding (af€er solids have been

introduced) for up to two years or beyond.

(6) Age, rather than hcome, may be a more successful variable in identifjing women

likely to introduce early solids. This is because of the sensitivity of disclosing farnily

income, and the larger percentage of women who refused to disclose their income in

this study.

(7) Regarding breastfeeding, the 'culture of misinformation' must be dealt with by

providing, to everyone concerned, accurate, curent infiormation about the advantages

to women and children of choosing to breastfeed. For breastfeeding to be successful,

the following must occur: an environment of awareness and support, an increase in

women's confidence in their ability to breastfeed and the elirnination of obstacles

within the health system, the workplace, and the comrnunity.

(8) It is recornrnended that qualitative data be collected. This type of information will

help in understanding how personal and socio-economic and cultural factors interact,

and how they shape behaviour.

4.9 Conclusions

This study was successful in providing a better understanding of the factors

associated with the early introduction of solid foods and thereby identiwng mothers who

will benefit most h m health initiatives. Mothers tend to inb-oduce solid foods before four

rnonths of age if they do not breastfeed, are younger, have less education, smoke or have

partners that smoke, and do not receive adequate support after birth.

This study provides the ûttawa-Carleton Health Department with information about

mothen that tend to introduce solid foods before four rnonths of age. In understanding the

mothers' knowledge, attitude and behaviour, and in discovering the source of incorrect

advice, inappropriate infant feeding practices can be addressed at the root of the problem.

Future infant health promotion programs c m then be appropriately targeted.

This study's results have indicated that there is need for education programs, based

on the CPS guidelines, for health professionals who work with the target group, for these

mothers and their partners. In addition, educational programs should be broadened to

include t h s e people most likely to have an influence on a mother's decision regarding infant

feeding (i.e., the mother's partner, close family and fnends). The programs should focus on

breastfeeding and support issues for expecting mothers who are younger, less educated and

are smokers. Their partners should be included in these programs. Breastfeeding and

support are complex issues that should be dealt with by using a population hedth

perspective. In this way, the many different factors of a mother's life can be addressed.

1 O3

The programs should focus on much more than health information. They must work

towards a supportive environment that wiU enable a mother to practice optimal infant feeding

methods. For example, programs shouid focus on increasing a mothers' Rsources (clear and

concise information on infant feeding guidelines, breastfeeding support, paid maternity

leave) as this may have the greatest impact towards improving infant feeding patterns.

List of appendices

Appendix 1 - A Summary of Canadian uifant Feeding Practices (see back jacket of thesis)

Appendix 2 - Letter of Understanding

Appendix 3 - Ethics Approval

Appendix 4 - 1988,1992 and 1996 Survey Objectives

Appendix 5 - 1988 Parent and Child Health Survey

Appendix 6 - 1992 Infant Care Sunrey

Appendix 7 - 1996 Infant Care Survey

Appendix 1 - A Summary of Canadian Mmt Feeding Practices

Study specifics

- 98 children under 5 years Sample representative of

population in the Eastern Townships, Québec - Cross-sectional study - Home interview

-

80 6 to 9 months olds in Halton Regional Health Unit area (Ontario) - Cross-sectional study - Home interviews conducted in Feb-March 1976

Purpose of the study

- To examine breastfeeding and the introduction of solid foods in infimts' diets.

- -- --

To examine relationships between maternai demographic, behavioural and attitudinai variables and infant feeding practices during first 6 months.

Results

- Cereals were introduced at a mec weeks; cooked vegetables at 2 ma months.

By 1,2,3 & 4 months, 37.5%,6' 92.5% of infants were receiving si respectively. Al1 but one mother h solids by six months. - 93.8% were given cereai as fbt Order of introduction was u s d l

vegetable, mats. - Age of solids introduction was pc correlated with duration of breastf controlled for mother's age, educti which in turn was related to the ml education and SES. The correlation between SES am

introduction was not significant w duration of breastfeeding.

Y - hg and foods

PS

a1 and infant fmt 6

Cereals were introduced at a median age of 3 weeks; cooked vegetables at 2 months; meat at 4 months.

By 1,2,3 & 4 months, 37.5%,67.5%, 829% and 92.5% of infants were receiving solid foods, respectively. Al1 but one mother had introduced solids by six months. - 93.8% were given cereal as fm solid, Order of introduction was usually: cereai, fruit,

vegetable, meats. - Age of soiids introduction was positively correlated with duration of breastfeeding (when controlled for mother's age, education and SES) which in tuni was related to the mothefs age, education and SES. The correlation between SES and age at

introduction was not significant when controlled for duration of breastfeening .

Comments and Conclusions

- Authors conclude that social pressures and long-held customs influence infant feedUig practices more than pediatric guidelines. - RecaiI bias is an issue due to age of some of the children at t h e of study .

Statisticai analyses are ody descriptive (kquencies).

Sample excluded unwed mothers and those who did not speak English. - Representativeness of the sample is not indicated.

1 Author

Bramble 1978

Mackey 1978

Myres 1979

Study specifics

107 Canadian (Can) and 1 10 West Indian mothers - Cross-sectional study - interview

- Random sample of 228 women who had delivered no more than 3 months previousty - Selected fiom birth records Cross-sectional study Home interview

. Newfoundland

- National survey for 1965- 197 1, collected during the Nutrition Canada Survey ( 1970- 1972). - Survey questionnaire & 24 hour dietary recall

Purnose of the studiv

- To study infant feeding practices of Caucasian Canadian and West Indian primiparae in relation to matemal personality characteristics and nutitionai know Iedge.

- To study curent infant feeding practices.

- To study retrospective data on infant feeding practices.

Results

- Breasifeeding (bf) for 3 months O

significantly higher in Can (55%) 1 motfiers. Botiie feeding mothers in foods significantiy earlier than bf r rnothers fed solids earlier than Can

Bf duration was significantiy con which soli& were introduced into 1

relationships were not signifiant f For both groups, there appeared tl

relationship between age at introd~ foods and some personality charac

- Solids introduced early: 12% by : 4 wks, 92% by 8 wks, and 100% b mothers fed solids in the boale. - Early intro solids made without p advice.

Introduction of non-mik sotids O(

rnedian of 1-2 months with a natioi rnonth. About one-half the infants were i~

solids by 1 month and between 80- months.

Mothers who breastfed tended to Iater (median three months) cornpa feeders (median one rnonth). Thosc combination weaned at median of.

Results -- -

Breastfeeding (bf) for 3 months or more was significantly higher in Can (55%) than Wi (33%) mothers. Bottle feeding mothers introduced solid foods significantIy earlier than bf mothem WI mothers fed solids eariier than Can. - Bf duration was significantly correlated with age at which solids were introduced into diet of Can; these retationships were not significant for WI. For both groups, there appeared to be a significant

relationship between age at introduction of solid foods and some personality characteristics

Solids introduced early: 12% by 2 weeks, 43% by 4 wks, 92% by 8 wks, and 100% by 12 wks. 25% of mothers fed solids in the bottie.

Early intro solids made without professional advice.

introduction of non-miik solids occurred at a median of 1-2 months with a national median of 1 month. - About one-half the infaats were introduced to solids by 1 month and between 80-90% by three months. Mothers who breastfed tended to introduce sotids

iater (median three months) compared to bottle feeders (median one month). Those who fed a combination weaned at median of 2 months.

Comments and Conclusions

The study does not provide information about: dates, representativeness of the sample,

- how the sample was collected, - control for any variables

- Study only provides fkequencies; there are no correlations with any variables.

- The analyses are only descriptive, therefore they cannot control for variables.

1 Author

Yeung 1979 & 1981

Clark 1981

- 403 infànts: 19 1 fiom Toronto & 2 12 fiom Montreal. - Prospective cohort study Erom birth to 18 months (10 follow- up periods); home interviews. Toronto (Jan 1977-Dec '78)

and Montreal (Feb '77-Jan '79).

42 1 rnothers in 4 Manitoban hospitals Prospective cohort study

- October 1977-Match 1978

Purpose of the study

- To determine infant feeding practices fiom bùtb to 18 rnonths in Toronto and Montreal, To assess nutritional

adequacy of Uifant diets, and To examine growth and

development of infants in relation to foods consumed.

To investigate current infant feeding practices and the factors that influence these practices, so that educational programs could be aimed at the areas of greatest need.

- The median time of solids introduc less than 2 rnonths. At 1,3 & 5 moc 79.1% and 97.3% of infants were gi respectively . Non breastfed (nbf) infants introdi

earlier than breastfed (bf); rime of i~ infants given breastmilk supplemen milk was intermediate. - By 1 month 32.5% were fed cerea 56.4% nbf. With the exception of j~ more nbf infants were fed foo* fio than bf infants. . The order of intro milk foods: cereals, h i t s , vegetablc meats, dinners, desserts, other. Rice common cereal given.

- 70% of breastfed and 88% bottle-1 received sotids by three months. - infants who were bonle-fed fiom I solids earlier than infants who were @<0.005) When solids were introduced befo

average age was 4.2 weeks for boa1 weeks for breastfed. At 3 rnonths, 94% of those on soli

63% ate bit, 38% vegetables and '

infants fiom famiiies with low SE earlier than infants 6om families w (p<0.005).

Y - ding 1 I

and

1

ed.

- -

;ifant

se onal i at the

Results

The median time of solids introduction was slightly less than 2 months. At I , 3 & 5 months, 64,4%, 79.1% and 97.3% of infants were given beikost, respectively . Non breastfed (nbf) infants introduced to solids

earlier than breastfed (bf); t h e of introduction to infants given breastmilk supplemented by bottIed- mük was intermediate.

By 1 month 32.5% were fed cered: 15.4% bf and 56.4% nbf. With the exception of juices at 1 month, more nbf infants were fed foods fiom each group than bf infants. . The order of introduction of non- milk foods: cereals, h i & , vegetables, h i t juices, meats, dinners, desserts, other. Rice cereal was most common cereal given.

- 70% of breastfed and 88% bottle-fed infants had received solids by three months.

Infants who were bottle-fed fiom birth received solids earlier than infants who were breastfed @<0.005) - When soiids were introduced before 3 months, average age was 4.2 weeks for bottle-fed and 6.7 weeks for brecistfed. At 3 months, 94% of those on solids atc cereals,

63% ate fiuit, 38% vegetables and 12% meats. Infants fiom families with low SES received solids

earlier than infants from families with higher SES (p<O.OOS).

Comments and Conclusions

- Results indioate that there is a trend for later introduction of solids, but that CPS guidelines are not followed by a majority of mothers. The sample was limited to EngIish and French speaking

women and did not represent the lowest SES appropriately; representativeness of the sample is not compared with the generaI population. - Participants Iost to follow-up were not compared with the rernaining sample. Data analyses only provided fiequencies.

- Statistical analyses did not conîrol for ottier variables. SES representativeness of sample is uncertain as it

excluded mothers who could not speak or understand English & those still under sedation, but did include unwed mothers.

Mothers Ion of follow-up (35/456?6) not compared with study group.

Data not uniforrnly collected (mix of telephone, mail and home interviews); did not verify if data was different based on collection method.

=

Heaith & Welfare Canada 1982

Tanaka 1987

Greene- Finestone 1989

Study specifics

Nationai survey of mothers with children under 2 years of a s - - Cross-sectional study - Mail questionnaire

- 404 mothers of infants 4- 15 months old. Toronto; M y 1984-Feb 1985.

- Cross-sectional study - Home interview

- 320 infants (6- 18 months) randomly selected fiom case- room birth records of 4 general hospitals (70% of Ottawa- Carleton birttis). Cross-sectionai study Home interview

- My-Decem ber 1 984.

f urpose of the study

- To provide data on the incidence and duration of breast-feeding, as well as information on the extent of hospital donation of infant formula

To provide current information on infaat feeding practices in metro Toronto.

To rnonitor infant feeding practices so that high risk groups might be identifie& and con tro 1 led effectiveness trials of nutrition education programs might then be developed, and - To describe infant feeding practices and associated demographic factors.

Different patterns of solid feeding between breast and bottie fed babie for botîle fed babies to be introducel earliec at 2 months, 40% boule fed 20% breast fed. - Mothers with fowest education teni solids early: at one month of age, 2C 8,3% for other educational levels.

- At 3 months, 42% infants received The median age at intro to sofids w At 4 months, 42% received infant (

months 93% had been introduced to

-

- Mean and median ages of solids in1 4.3 and 4.0 months.

Propotion of infants fed solids < 3 inversely related to SES level (p~0.a - Age of solids introduction was infii of milk feedbg chosen: a higher deg bredeeding was associated with a ! later introduction of solids @=0.000:

? -

of it

h g O.

- 'g

and ials

'g

-

Resdts

- Different patterns of solid feeding were evident between breast and bottle fed babies with a tendency for bottle fed babies to be introduced to solids earlier: at 2 rnonths, 40% bottle fed compared with 20% breast fed.

Mothers with Iowest education tended to introduce soli& early: at one month of age, 20.5% vs 4-3- 8.3% for other educational Ievels.

At 3 months, 42% infants received solids. The median age at intro to solids was 4 rnonths.

- At 4 months, 42% received infant cereai, by 6 months 93% had been introduced to ce rd .

Mean and median ages of solids introduction were 4.3 and 4.0 months. - Proportion of infants fed solids < 3 mos was inversely related to SES level (p<O.OOS). - Age of soli& introduction was hfiuenced by type of mik feeding chosen: a hïgher degree of breastfeeding was associated with a significantly later introduction of solids @=0.0003).

Cornments and Conclusions

AI1 analyses are descriptive, and none control for other variables.

- The results indicate that feeding practices are more closely aligned with CPS guideiines than in 1977-78 (Yeung 1981). No cornparison of the sample to the general population. The analyses only include fiequencies.

- Conclusion: despite CPS recommendations, 33.8% received solids < 4 montiis. Cornpliance with CPS guidelines is poorest amongst Iowest SES.

Statistical analyses were chi-square and t-tests; these cannot control for other variables. The iowest SES group as under-represented. Otherwise,

the sample was representative of the population.

h

Sauve 1991

Spigelblatt 1991

CarcelIer 1995

Stndy specifics

- 1 14 term infants fkom the Calgary Heaith Services Well Baby Clinics in 198 1 & 1982. - Prospective cohort study - Home interview

- 1 10 infants recruited over 10 months at a Montreal university hospital.

Prospective cohort study Middle class sample

- 1 O6 pediatricians completed questionnaire (23% return rate), involves 288 children. Retrospective study Questionnaire sent to Québec

pediatricians to be filled out at 6 month periodic visit (using retrospective information fiom child's chart). - January-Apn1 1993.

Purpose of the study

To compare growth during the first two years life of a population of AGA (appropriate weight for gestational age) preterm infants who received neo-natal care but had no neurodeveloprnentai or puhonary residual, and To compare food intakes and

feedhg probtem fiequency to determine factors associated with growth.

An intervention study, to promote later introduction of solids, until at least 2 rnonths.

To determine infant feeding practices in Québec, and to evaluate to what extent CPS guidelines were followed.

Data for control (tenn) infants only Semi-soli& were uitroduced into (

4 month ol&, Ingestion of inf'ant cereals was rep

of 4 month olds.

Data fiom control goup only: - 33 babies (3 1 %) were having solic months. Significantly more babies i before 2 montfis who were fed othei than breast milk (3%) @=0.006). The average age for introducing SC

wks. Families of higher SES uitroduced

Cereals were started at 3,511 mon1 4.5h2.6 mos; fniits 4.e0.9 mos; mi

rnos. - Age at which solids introduced wa signi ficantly di fferent for breast and although former were older (3.7k0.5 p<O.OS).

ly - h g : a

infants :are

es and icy to ated

Data for control (term) infants ody: Semi-solids were introduced into diets in 58.6% of

4 month O[&, - ingestion of inEant cereals was reported in 14.0% of 4 month olds.

Data &om control group ody: 33 babies (3 1%) were having solids befnre 2

months. Significantly more babies were fed solids before 2 months who were fed other rnilks (97%) than breast miik (3%) @=0,006). - The average age for introducing solids was 12.3 wks. - Families of higher SES introduced solids later.

Cereals were started at 3.5* 1 months; vegetables at 4.5k2.6 mos; bits 4.6I0.9 mos; meat at 5.710.6 mos, - Age at which solids introduced was not s ig i ficantiy different for breast and formula- fed, although former were older (3.71t0.9 vs 3.0 t 1 mos; p<O.OS).

Comments and Conclusions - - - - - - - - - - - -

No cornparison of (tenn) refiisals with those who participated. - Representativeness of the (tenn) sample is not indicated. - The objective of this study was not to describe i n b t feeding practices, nor SES factors therefore many of the variables in which 1 am interested were not collected. Analyses ody included fiequencies.

This sample is fiom middle class families. therefore it is not representative of the population at large. - The analyses only compared the two groups via t-tests; no regession analyses were conducted.

-- -- - -

- Conclusion: infant feeding practices seem to lag behind CPS guidelines, but this can't be seen as representative of Québec due to response rate. Physicians were representative of whole group regardmg

sex and type of practice, but not for years of practice (42% of respondents had practised for 1 1-20 yrs, but 40% of al1 pediatricians in Québec have practised 10 yrs or Iess). This may have introduced a bias in results through nutrition knowledge. - Study does not indicate if children representative of population, however results are in accordance with two other Montreal studies.

Matthews 1995

Valaitis 1996

Study specifics

- 773 mothers, representing 12% of population having given birth in region in 1992. 6 month prospective cohort Newfoundland & Labrador

- 132 women with six month olds Cross-sectional study

- data collected by telephone fiom January - March 1 993 - HamiIton- Wentworth

Purpose of the study

To explore reasons for maternai feeding choices and influences on mothef s decisions in Newfoundland and Labrador.

To determine infant feeding uton. practices in the rem-

Results

- Breastfeeding @f) mothers are les bottle-feeding mothers to start solid than recommended. At 1 month: 0.1 bottle were given cereal. At 4 and 6 respectively: 63% and 9 1.6% of bf having soli& compared with 78% ; fed infants. Almost al1 babies given solids wei

By 4 rnonths, of the 78% on solids, having fniit, 29% vegetables and 2. months, almost every bonle-fed bal taking cereal, 82.2% fruit, 89.3% v 27.5% meat.

Cereals and solids were initiated t recommended times (does not give even more evident in infants that w breastfed.

Y - ; and

ind and

Breastfeeding (bf) mothers are Iess likely than bottie-feeding rnothers to start solid foods earlier than recommended- At 1 month: 0.8% bf vs 52% bottle were given cereal. A t 4 and 6 months respectively: 63% and 9 1.6% of bf babies were having solids cornpared with 78% and 98.9% bottle- fed infants. Almost al1 babies given solids were taking cereal. By 4 months, of the 78% on solids, 30.4% were having fniit, 29% vegetables and 2.5% meat. By 6 months, almost every bottle-fed baby (98.4%) was taking cereal, 82.2% fhit , 89.3% vegetabie and 27.5% meat.

Cereals and solids were initiated before recommended cimes (does not give ages). This was even more evident in infants that were never breastfed.

Comments and Conclusions

Conclusion: as a group, bf rnothers came closest to following CPS guidelines: later introduction of solids, less likely to introduce less digesti'ble foods (eg. meat) at an ear lier age. - Analyses used t-tests and chi-square therefore did not control for variables.

- Infant feeding practices in Hamilton-Wentworth are far fkom meeting CPS recommendations. - No cornpairson of the sample to the rest of the population. - Statistical analyses include chi-square, but this does not control for other variables.

434 9 month old infants. Selected nom birth lists

provided by Vancouver HeaIth Dept. - Babies bom between Jan 1 - March 2 or lune 4 - August 7, 1993. Cross-sectional study

- C h i c interview at 9 months,

350 new mothers breasfeeding be fore hospital discharge. - Selected on the only perinatal unit in the Sudbury region. Prospective cohort, at onehwo

weeks, 3 and 6 months by questionnaire. 50 mothers in control group,

questionnaire only at 6 months.

Purpose of the smdy

To assess mt feeding practices and to compare them with CPS guidelines and with data fiom previoüs Canadian studies.

To provide data for the planning and development of services airned at promoting, protecting and supporting breastfeeding for the recommended 6 month period.

- -

Results

- An association exists between dura1 breastfeeding and age of solid food i Most infants were introduced to sol

rnonths: 90.1 %, 70.7% and 70 2% gi fortified infant cereal, vegetables am respective ly . - Before 4 months: 7.8% fed iron-for 1.8%, 2.5% and < 1% given vegetab other food respectively. By 6 and 9 r respectively, 9.9% and 4.0% had noi iron-fortified infant cereal. - Meats. chicken, fsh, egg yolk and commonly introduced between 7-9 u 33% and 62% of infants had not bee chicken, meat or f ~ h , respectively.

- 1 % of infants were fed soIids at 1 m rnonths, and 93% at 6 rnonths. Mothers feeding solids at 3 months

than who were not to still be breastft (p=O.OOO 1). - One of the reasons given for stoppi breastfeeding was the introduction O

Y - r

: them with dian

nt of ting, g

~eriod.

Results

- An association exisrs between duration of breastfeeding and age of solid food introduction. - Most infants were introduced to solids between 4-6 rnonths: 90. IYo, 70.7% and 70.2Y0 given iron- fortified ~t cereal, vegetables and üuit respectively.

Before 4 months: 7.8% fed ka-fortified cered, 1.8%, 2.5% and < 1% given vegetables, h i t , or other food respectively. By 6 and 9 months respectively, 9.9% and 4.0% had not been given an iron-fortified infant cereal. - Meats, chicken, f ~ h , egg yolk and legumes most commonly introduced between 7-9 month; 24%, 33% and 62% of infants had not been introduced to chicken, meat or fish, respectively.

- 1% of infants were fed soli& at Imonth, 32% at 3 months, and 93% at 6 months. - Mothers feeding solids at 3 mon& were less likely than who were not to still be breastfeeding (p=o.OOO 1). One of the reasons given for stopping

breastfeeding was the introduction of solids.

Comments and Conclusions

Results indicate that infant feeding practices are more closely aligned current CPS recommendations than previous Canadian studies, however there were notable discrepancies among some groups- The sample was not compared with the general

population. Regardhg the solid food data, only fiequencies were

provided; analyses did not compare soiids introduction with breastfeeding or the mother's socidernographic factors.

- This study focussed on breastfeeding, therefore the analysis regarding solid foods was minimal. - Statistical analyses inchde chi-square, but this does not control for other variables.

Appendix 2 - Letter of Understanding

The following letter of understanding is among Beth Kwavnick (Dalhousie MSc student, Community Health and Epidemiology), Nicki Sims-Jones, RN, MScN? and Debra Reid, PhD, RD, of the Ottawa-Carleton Health Department.

This is to confirm that Beth Kwavnick has access to selected data fiom the Ottawa- Carleton Health Department Infant Care Surveys conducted in 1988, 1 992 and 1 996, which she may use in the preparation and submission of her Master's thesis. Beth Kwavnick will have access to the data pertaining to the introduction of solid foods, the infant's birth weight, the mother's par@, age, education, family incorne, presence of a partner, breast and/or bottie feeding history (with the 6 month old), baby and mother's health since birth, support (financial a d o r social), exposure to environmental tobacco smoke in the home and tobacco use by the mother.

It is understood that the data belong to the Ottawa-Carleton Health Department, and that Beth Kwavnick may not publish them without prior permission nom Nicki Sims-Jones. However, Beth Kwavnick c m submit these data, as part of her thesis to her academic thesis cornmittee at Dalhousie Univers@ without pnor permission &om Nicki Sims- Jones.

Beth KwaMick has six months fiom the date that her thesis is successfully defended to submit a paper for publication. The order of authon will be: Beth KwaMick, Dr. Debra Reid, Dr. Judy Guernsey (Dalhousie University) and possibly another thesis comrnittee member. If Beth KwaMick does not submit a paper for publication within six months, Dr. Debra Reid has the option to prepare a paper on which she will be first author. Dr. Debra Reid has agreed to be a mernber of Beth Kwavnick's thesis cornmittee.

The 1988, 1992 and 1996 data described above have not yet been analyzed in the manner in which Beth KwaMick proposes below. n ie Ottawa-Carleton Health Deparûnent has not been able to allocate the resources to perform these analyses. The work proposed below will be the only in-depth analyses of these data, which Beth Kwavnick will use in preparation and submission of her Master's thesis. The Ottawa-Carleton Health Deparûnent WU find these analyses helpful as they:

(1) wili provide a picture of infant feeding practices, specifically the introduction of solid foods in ûtiawa-Carleton for three time periods (1 98 8, 1 992, 1 996) and,

(2) will assist in planning future infint health promotion programs.

Upon completion of her thesis, Beth KwaMick will provide the Ottawa-Carleton Health Department with a copy, to be placed in their library for friture reference.

Plan of the Thesis

Phase I

As part of Beth Kwavnick's masters thesis, she wiU use data (specified above) which has been collected by the Ottawa-Carleton Health Department as part of three Infant Care Surveys conducted in 1988,1992 and 1996. Each of these surveys includes a cohort of parents with six month old babies. Beth KwaMick will examine at what age breast and formula feeding, and solid food initiation occurred (1 988, 1992, 1 !M), what solid food was first @en (1988, 1992,1996), and in what order subsequent solid foods were introduced (1996 data only). This wili be done via kequency analysis, and descriptive results. Also inciuded may be an analysis of trends over the three surveys, regarding the solid food data.

Phase 2

This section will be detailed upon cornpletion of Phase 1. Phase 2 will be based directly on the (successfülly defended) thesis proposal prepared by Beth KwaMick, in co- operation and consultation with her thesis cornmittee. The proposa1 will consist of statistical analyses, a literature review and discussion with key informants in the field of infant nutrition.

The statisticai analyses will iikely examuie the solid food data (based on the resuits of Phase 1) in relation to the infant's birth weight, the mother's parity, age, education, family income, presence of a partner, breast andor bottle feeding history (with the 6 month old), baby and mother's health since birth, support (firiancial andor social), exposure to environmental tobacco smoke in the home and tobacco use by the mother.

Timelne for 1997:

January: halize and sign the letter of understanding mid January: conduct a fiequency anaiysis of some of the data as descnbed in Phase 1 for preparation of an abstract by Dr. Debra Reid end January/early February: complete the fiequency analyses as described in Phase 1 in order to get a "feel" for the data February & March: design Phase 2 (the thesis proposal). April: defend the thesis proposal and finalize Phase 2. Phase 2, based directly on Beth KwaMick's thesis proposal will include a timeline for the statistical analyses (likely to be conducted in the late spring or early sumrner), as well as for the remainder of the thesis.

Beth Kwavnick Debra Reid Nicki Sims-Jones

Letter of Understanding - Phase 2

The following letter of understanding is among Beth Kwavnick @alhousie MSc student, Community Health and Epidemiology), Nicki Sims-Jones, RN, MScN, and Debra Reid, PhD, RD, of the Ottawa-Carleton HeaIth Department.

The purpose of this letter is to detail Phase 2 of Beth Kwavnick's thesis. Phase 2 will be based directly on Beth Kwavnick's thesis proposal, which was successfully defended on July 25, 1997. AU other tenns of agreement are deiailed in Appendix 3 of the proposal.

Proposed theris tirneiine (I 99 7)

August & September: data analysis October & November: interpret analysis & discuss results December: thesis defence

Beth Kwavnick Debra Reid Nicki Sims-Jones

September 12, 1996

Niclci Sims-Jones Ottawa-Carleton Health Depamnent 495 Richmond Road Ottawa, Ontario KSA 4A4

RE: Project # 96-05 - "Infant Care Survey"

The Ottawa-Carleton Health Department Research Ethics C o d t t e e has deemed p roject #96-05 ethically acceptable. The scientific reviews and Cornmittee member comrnents are included for your use.

The Cornmittee requires a request for a renewai of ethical approvai by Oaober 3 la of ach year that the project is active. Ethical approval will be withdrawn if the Cornmittee does not receive th's report by Onober 3 la An end of project report is also required Please refer to the Research Ethics Cornmittee's T e m of Reference and Procedures for copies of these t o m .

Sincerely, n

bbi Reuven Bulka

cc. Claudette Nadon

-< Rcfional Sluniripdity of <>tiarn-<-rrlatun -- Slunieipdici egionïle GOttawa-Carletm :v--

Iit..ti:h !br~.wtrnvnt $ ,Pr,< ,! 5,r . ; rv rio ! L - . t *~t -

&": 8;:nrr;t.nd Rri~d ; ', f - , f $!+>. citt.rii:z Ric:.n:o~:.:

June 12,1997

Beth ICwaVnick, 452 Golden Ave, Ottawa, ON K2A 2E5

Dear Ms Kwavnick,

In answer to your inquiry regarding the Ethics review process for the 1988 Parent Child Health S w e y and the 1992 Infant Care S w e y carrïed out here at the Ottawa-CarIeton Health Department, this letter is to inform you that the Ottawa-Carleton Health Deparmient does indeed have a research Ethics Committee and that both these -dies were reviewed and approved by this Committee.

1 wish you well in your Maners research and look forward to seeing the results of your analysis of the infant feeding trends here in Ottawa-Carleton.

Sincerely,

Pauia Stewart M.D..F.R.C.P.C. Associate Medical Officer of Health

Quality serrice delirerd trith cure. Des semices de qualité, arec humanité, corn petence and in tcgrity. compétence et integn'fé.

Appendix 4 - 1988,1992 & 1996 Survey Objectives

The foUowing objectives are those f?om the original surveys, as described by the principal investigator of the m e y .

1988 Objectives: 1. To determine the p~valence of socio-demographic and lifestyle factors which rnight influence the heaIth status of pregnant women, infants and their parents. 2. To deterrnine present use of preventive health care and community programs. 3. To detennine the interest in existing and proposed new Health Department programs. Principal Investigator: Pada Stewart, M.D., F .RC.P.C

1992 Objectives: 1. To assess identified aspects of the care given to six month old infants. 2. To assess the utilization of. satisfaction with and awareness of group programs offered by the Health Department in Ottawa-Carleton to parents of infants. 3. To determine the health needs of six month old infants and their mothers as perceived by the mothers thernselves. 4. To determine the prevalence of both individual and environmental factors which might influence the hedth status of six month oId infants and their mothers. 5. To assess the eariy postpartum experience of mothers of six month old infants. 6. To assess the mother's breastfeeding experience with this infant. Principai Investigator: Nicki SirnsJones, R.N., M.Sc.N

1996 Objectives: 1. To compare breastfeeding initiation and duration rates before and d e r the changes in matemity care services. 2. To compare the other infant care practices of mothers of three and six month old infants after the changes in matemity care services. 3. To compare the early posrpartum experiences of mothers before and after the changes in matemity care services. 4. To deterrnine the utilisation of, satisfaction with and awareness of programs offered by the Ottawa-Carleton Health Department to parents of infants. Principal Investigator: Nicki Sims-Jones, R.N., M. Sc .N

Appendix 5 - 1988 Parent and Child Health S m e y

Study N u s b e r - -

INTERVIEWER: READ ALL BOLD TYPE -

Pe~son answerlng questions - rcothez f ather

Haw many chiïdran do yaa have living w i t h p u at

Child 1 Child 2 Child 3 Child 4 Child 5

1. men your baby aras a newbrn, did you breast feed or bottle feed at firsl?

- B R U T - la. Are p u giving or did p u give a d d i t i o d milk feedtngs on a reyular basis (at least once per dap) w h i l e still nursing?

no (,go to question lb) When did yoa start?-w)cs or -ntos, m t aia %il give? -- foniula - specify type

homorni Ek - 2% milk - s k i a m i l k - - - evaporated - other (specify) -

lc . Wy did p u stop breastfeeding? (check al1 that apply) - not enough milk - return to work or school - babp didn't w a n t to continue

-1 didntt w a n t to continue - 1 thoucrht it was time to stop - - ~h~sician told me to

A mother . . Ill - mastitis - too tired - other(specify) - Id. What kind of milk are yoa feeding p p o a r

mu? (check al1 that aoply) , breastmilk

..A f onnula - specify type - homogenized mi= -'A - 2% milk - akim milk - evaporated - - other: (specify) -

Go to Question 2

1.1 SOTPLE - a. W h a t kind of milk did you use w h e n the baby was first bon? - f ornula - soecify type - 2% miL? - whole milk - evaporated milk - -other (specify)

foanula - specify homogenized milk 2% milk skim milk

type

' evaporatecl. - - othar (specify)

C . Ubxl did 8 9 start feeding p~ batrp. +bis kiod 0 -W? montha of age

- months of age What so l id food did p u start w i t h ? - cereal - fruit - vegetables - meat - teething biscuit/cookie

other

(check one)

DO now or have poo Fn the pas+ pat poar baby to bed with boltle? - no

_es - What is or was in the bdtime boftle? - milk - water - juice - cereal and miUc - other ( spec i fy )

ta help w i t h ( check

soother teething ring cookie orage1 tempra other medication (speci fy ) o t h e r ( specify )

water q s t e m connectecl to a w e l l ?

- Does ywmr M d ciru or do p u plan chiid &ink the w e l l w a t e r ?

Have p u no

for

for

fluoride? '

6 . Are pou giving or did p u give snppleme~lts?

- Wat spplpmc~nts are Tri -vi-sol

you gfv+ng?

with fluoride

121

f luoride

- - have same concexns or worries about h m to care for lmny patents

the* child or the cbild's dwelopment. .

- no yes - R h t sort of concenrs do ~ Q Q have? (let respondent

use own words then p u t concern into one of the

cr~ring feeding . stimulation what 1s normal development sleeping out-of -home care colic health problems other

8 . Do p u get help or a M c e frrin any of the follawing w h e n p u have concar~s abmt ynur baby? (read out options and ask if use of ten,

as your batry-had aB accident uhere he had to be t a k ~ to the emergenq departmat?

- Y== aga at time of accident

Wt happened? - fa11 inside home - in juzy outside home - ingestion/poisoning - - motor vehicle accident - other

10 . Does y m r babp have a disabilitp? - no - Y- Haw does the disabLLity affect the child?

Wen p u are drivipg in a car w i t h ~ P T babp, haw often is he/she in an app~aved carseat and buckled up? - &=F - most of the t h e - s 5 e of the t- - rarely or ne-

don0 t drive

Do pou haire the folluwing in pur home? - A smke detector - no .-. Y= A fFre m g u i s h e t - no .-, yes .

Do y00 have a m g pool in the barn? - no

yes - Is there a f a c e atomrd the yard? 1s th- a fence amPnd the pool7 1s theze a lock on the gate?

- -no yes - no yes - no - Y==

mexe are medications stored in y o e horise? (Check one or more) unlocked l o w cupboard or drawez - - locked unlocked high storage area, out-of-reach of children - - othes (specify)

lühere aire c h d c a l s , cleaaing matetials etc. stored in pur house or garage? (check one or more) (Do not read responses)

unlocked l o w cupboard or drawer locked unlocked high storage azea, out-of-each of children other (specify)

QUESl!IONS ARE ABOUT POUR USE OP HEnLTB CARE SWVICES

Do porr have a doctor foz p a r children? - no yes - 1s the doctor a family doctor or pediatrician? - family docto~ - pediatrician

- LAW - yes - where did p u go t o get them? doctor's office

first time? - age in years - 1 don't know

NQ21. Has a public health nruse popt hame since baby - no

yes Haw - C o p t a c t e d was barn?

m s -a. -P&lic?.health nurse visited p u h yout home since p u r baby was bon? -. . - no - -yes - How many t h e s have you seen h a ? times

Haor usefui did p u f ind the visit ( s ) ? - very usefd somewbat usefui

Bave yoo been to axty Patent Child Discassion groupa offered by the Health De-t? - no - D i d pou h u w a h t th-? no yes , Y=

Wodd y o ~ be interested fn go-g to P a z e n t a d Discussion gronps off ered by the H e a ï t h De-t in the future? - no . , Y- - Wh- wmld you like to have them? (check one or more) - aorpfpg ,- aftesnoon w a g

~ a v e p u attended anp othex act iv i t ies or drupins with this

- no - yes - w h i c h ones dtd pou attend? - music - s -g/gym - &op-in/playgroup - discussion grouos - othez

the

2 6 . Did yop smoke in the month before p u became ptegnant w i t h your most recent &Id?

- Y- D i d p u smoke

smoking after the

Do p o ~ f& you get as much exercise as yoo need or less than p u need? ; . as mpch as needed - - legs than needed - don ' t hm

Aze you l-ted in the kind or munt of activitp p u can do becanse of a long term phps icd condition or health problem? long te- 1 mean a condition that has lasted or is erpectd to las+ nmre than 6 zwnths.

dwftp? public school - grade high school - grade some college some University completed college completed University (one degree ) postgraduate degree

126 . child is s i & or if the usual are not m i l a b l e ? wclric mo ther partter - stay home from .- ---- - - - - - f d l y member cares for child

friend or neighbout c a e s for chi ld - --- - - othet ( specify )

w h a t is pour t o t a l family incane before taxes? ranges for you.

less thao $10, ooa $20,000 $25,000 s ~ O ,000

H m many adnlts and hov many children are supporteci 6th this incame? numbet of adults number of children

U o d d p u describe yoftr l i f e in g e n d verp stressfaL

or bad

help '

couid taik +O if p u needed help Do yoa have sameone a ' p r o b l d

- - no ves Please describe vhat these s e c e s wodd be.

Wexe pou born in Canada?

- no - H m =y yeaxs ago did p u arrive in Canada? - less than one year - one to two years - three ta fout yeazs - five or more years

,- Y==

Fmat laquage@) aze spoken at hane? (check a l 1 that apgly)

english french chinese

- vietnamese

spanish - laotian portuguese - cambodian o t h e ~ (specify)

îs popr CMePt m a r i t a l status? maxriedfconmion law single/never w i e d separateci divorced widowed

p u ( 1 s the childos m o t h e r ) preseatly wrking and earning mon-? - no (Go to Question 36)

yes - Fmen did p u (she) begin to work aftet the baby8s weeks or - months b i a h ?

Is t)ifs & outside the home? - no (Go to Question 36) Y= - Wha+ chiidczue arraugements do p u have for

p u r babg/ather de age 59 (ask about baby fizst, then o t h a children)

=w licansed home daycaxe daycae centre -

. . babysittex8s home % - parents'share childcare xelative p~ovider care father provides care babysittes in pur home other -

4 2 . For OPT records is tb is yow. correct address? (read off printout 1. If not what is par adùress? (include pos~al code) Re -1 analyse data by area of ci*. (make any c o n e c t i o n s on label )

TbaPk. p u fox participa+ring Fn the stohp.

INTERVIEWER: READ ALL BOLD TYPE

Motha to answer questions

How many children are living with you? - child(ren)

What are their birth dates? monthday Year

1 WOULD LIKE TO BEGIN BY ASKING YOU SOME QUESTIONS ABOUT YOUR YOUNGEST CHILD.

1. What type of birth did you have? vaginal cesarean

2. What was your due date? *=Y Month Year

3. How long did you stay in hospital after the birth of your youngest &Id? Hours Days

4. H o w did you feei about the length of stay in hospitd after the birth of your baby? Was it:

too short OK too long

PIease, state the reason for your answer

S. Who heIped you when you d v e d home after the baby's birth? spouse\ part~er mother mother-in-Iaw

- paid help - other (speas.)

6. Did you have any problems caring for your baby when you came home? - no - yes -> If yes, what were your problems?

7. When dÏd you decide to breast or bottle feed your baby? - More pregnancy - during pregnancy - after the babyls birth

8. What were your feelings about breastfeeding before your baby was bom? (inte~ewer to categorize) Do not read options

more time-consuming than bottle feeding better for my baby

- better for the famiiy less costiy Iess convenient

- more d i f f id t than bottle feeding interferes with sex family carmot pafticipate more convenient better for me less time-consuming than bottie feeding

- easier than bottle feeding unacceptable to partrier too embarrassing would tie me down anxious/ worried positive/determined

- other (spedy)

Was breastfeeding disçussed with you during your p r e p c y ? - yes -> Who discussed breastfeeding with p u ?

Physiaan Prenatal instructor Friend who has breastfed

- other(specuy) - no, breastfeed not discwed - dont recd

10. H o w were you feeding your baby in the hospitaI? (ch& one) breastfeeding

- bottie feeding - both - mother's decision

m - both - hospital's decision

11. Did you or your baby have any medical problems that kept you from feeding your baby the way you had planned to? - no (Co to question 13) - Y=

8 2 d infection

INFANT jaundice

THE NEXT QUESTIONS ARE YOUR ABOUT GENERAL BREASTFEEDING EXPERIENCE

IF THIS MOTFIER NEVER BRJ%SEED HER BABY GO TO Q-ON 35, pane 10

13. How confident were yoa that you wouid do weU at breastfeeding? not very confident moderatdy confident very confident

14. Why did you decide to breastfeed your baby? (interviewer m

Do not read options to categorize)

better for m e better for my baby more convenient better for the famüy less costiy other - specify

15. How would you describe your breastfeeding experience when you first brought your baby home? (interviewer to categorize) Do not read options

unpleasant - good

unsuccess ful important e=Y pleasant bad successful unimportant diffïcult other

16. How wodd you describe your breastfeeding expenence overall? (interviewer to categorize) Do not read options

unpleasant good ~ u c c e s s f u i important

--Y pleasant bad successful unimportant

* diffïdt other

17. For how many months did you initidy plan to breastfeed? Iess than 1 month 1 or 2 months 3 or 4 months 5 or 6 months more than 6 months no specific tirne

18. Are you giving or did you give additionai milk feedings on a regular basis (at Ieast once per day) while still breastfeeding? t no (Go to question 19) - I Y-

Lf yes, -> How old was your baby when you started the additional feedings? - weeks or mon&

1% 4 What did (do) you give? 1 formula (specify Spe) - & whole miik - 2% milk - skim milk

evaporated miUc - 0th- (sp*)

19. Are you still breastfeeding your baby? 2 no (Go to question 20) - 1- yes, every feeding - evdusively breastxdk (Go to ouestion 22) 5 yes most feedings @ottle Iess than once a day) (Go to question 22) 4 yes, sorne feedings (bottk at Ieast once a day) (Go to aiestion 22)

If No, how old was your baby when you stopped breastfeeding? - weeks

months

What were the main reasons you stopped breastfeeding? (interviewer to categorize) Do not read options - not enough mük/hungry baby - sore nipples - engorged breasts - diffldty positioning the baby

- - felt tied down - returned to work or school

baby didn't want to continue - physiaan told me to stop

Iwasill I had mastitis 1 was too tired the baby's father wanted m e to stop planned to stop at this time baby wasn't gainuig enough weight other - speafy

If yes, how many times have you breastfed in the past 24 hours? less than 4 4 to 7

- 8 to 10 - more than 10

Did you experience any p d d a r difficulty during your breastfeeding experience? - no

yes - If yes,-> What were your particular difficulties?

Did you stop drinking mi& or eating dairy products while breastfeeding? - no - yes - If yes,-> Why did you stop?

25. Did anyone advise you to stop drinking milk? - no - yes - If y=,-> Who advised you to stop? (do not read options)

- p hysician - fiiend - Public Health Nurse - mother-in-law - mo ther - other (speafy)

26. Who gave you helpfd breastfeeding advice? (interviewer to categorize) 9

Do not read options baby's father my mother mo ther-in-law close fnend breastfeeding support group parent-baby information line doctor(s) midwife La Leche League prenatal teacher breastfeeding c h i c hospital nurse(s) public heakh nune printed information or video other - speafy

27. Did anyone give you breastfeeding advice that was & helpfd? - no - yes -If yes, -> Who gave you unhe1ph.i advice? (interviewer to categorize)

Do not read options (Check d that apply)

baby's father my mother mo ther-in-law dose friend breastfeeding support group parent-baby information Iine doctor(s) midwife La Ledie League prenad teacher breastfeeding dinic hospitd nurse(s) public health nurse printed information or video other - spedy

If yes, -> Did this unhelpful advice make breastfeeding difficult for you? - no - yes -> If yes, how did it make breastfeeding

difficdt for you?

28. Did you attend the Breastfeeding Support Groups held by the Public Health Department?

- no + Did you know they exkted? - no - yes

- yes -+ How useful did you find this group? very usefui - somewhat usefui - no t usefd -

29. How would you describe the support given by hospital staff for breastfeeding?

- ExceUent Good Fair Poor [7 bottlefed N/A

30. Did you receive a gift pack containing formula from the hospitd or from your doctor? - no (Go to question 32) - Y=

31. When did you use the formula? never first 2 weeks 2 weeks - 2 months after 2 months

32: Did you breastfeed any of your 0th- babies? no, this is my first baby (Go to question - 34) no, I bottlefed my other baby(ies) (Go to question 34) yes, 1 breastfed - babies

33. Was your Iast experience similar to this one?

- no - Lf not,-> How was it different?

34. Would you breastfeed if you had another baby? - Y= - no - undecided

INTERVIEWER NOW GO TO OLESTION 41

FOR BOTIZE FEEDING MOTHERS

35. Why did you choose to bottlefeed your baby? (using m i k other than breastrnük)

36. When you took your baby home, what kind of mi& did you use? formula - speufy type whole milk 2% miik

m

skim d k evaporated rnilk

- other (sp*)

37. What kind of milk are you feeding your baby now? 1 formula - specify type 2 wholemdk .3 2%&

skim milk 5 evaporated milk - other (specrfy)

How oid was your baby when you started feeding him/her this kind of milk? fiom birth weeks of age

39. Did you breastfeed any of your other babies? no, this is my first baby no, 1 didn't breastfeed any of my other babies yes, 1 breastfed - of my other babies

40. WouId you breastfeed if you had another baby? - Y S - no - undecided

ALL MOTHERS

41. Are you feeding your baby solids? - no (Go to question 44) - Y-

If Yes, When did you start giving solid food? months of age

42. What solid food did you start with? (check one) - cereal - f i t

vegetables - meat - teething - biscuit/ cookie - other - speufy

43. What solid food are you feeding your baby now? (check aiI that applv) - cereal - huit

vegetables - meat - teethhg - biscuit/ cookie

other - spec*

WE WOULD LXKE TO ASK YOU SOME MORE GENERAL QUESTIONS ABOUT INFANT CARE.

44. Do you give your baby anything to help with teething? (check ail that apply) - no - yes + What do you give? - soother - teething ring - cookie - oragd - tempra - other medication (specify) - other (spedy)

45. Are you giving or did you give your baby vitamin or nuoride suppIements? - no - yes - If yes, What supplements are you giving?

- Tri-vi-sol - Tri-vi-sol with fl uonde - D-vi-sol - Tri-vi-fluor - Pol y-vi-sol - Pol y-vi- fluor - Other - (specdy)

46: D o you now or have you in the past put your baby to bed with a bottIe? - no - yes - What is or was in the bedtirne bottle?

- miik - water - juice - cereal and mi& - other (specify)

MANY PARENTS HAVE SOME CONCERNS OR WORRIES ABOUT HOW TO CARE FOR THEIR CHnD OR THE CHILD'S DEVELOPMENT.

47. Do you have concerns or womes about your baby at this point in time? - no

y- -> What sort of concerns do you have? (let respondent use own words then put concem into one or more of the following ca tegories) - cry% - feeding - stimdation - what is normal development - sleeping - out-of-home care - colic - health problems

- weaning - teething

48. 1 wilI read you a list, please tell m e who would you go to for advice when you have concerns about your baby? (read out options)

Yes No Hospital nurse Midwife spouse/parhier famiIy friends doctor Public Heaith Nurse books magazines community groups other

49. Has your baby had an accident/injury where sfie had to be taken to the ernergency department? - no (Go to question 51) - ves -> If yes, What was his/her age at time of accidenqinjury? weeks

50. What happened? - fa11 inside home - something falling/spilling on baby - injury outside home - ingestion/ poisoning - mo tor vehicle accident - other

51. Does your baby have a disability? - no (Go to question 53) - yes - if ycs, How does the disability affect the child?

5 2 How does it affect you and your Me?

THE NEXT FEW QUESTIONS ARE ABOUT SAFETY

53. When you are driving in a car with your baby, how often is he/she in an approved carseat and budded up? - always - most of the the * - some of the tirne - rarely or never - don' t drive - don't drive with baby in car

54. Does the car seat face forwards or backwards? Backwards

Forwards - If so, is the seat tethered to the car at the back? VPC -*

- no

55. Do you have the following in your home? A smoke detector - no - yes A fire eutinguisha - no - yes

56. Does or did your baby use a walker? - no - Y S

57. Where are medications stored in your house? (Check one or more) - unlocked Iow cupboard or drawer - Iocked - unlocked high storage area, out-of-reach of children - medicine cabinet, unlocked - O ther (specify)

58. Where are chemicds, cleaning materials etc. stored in your house or garage? (check one or more) Do not read responses - unlocked low cupboard or drawer - Iocked

docked high storage area, out-of-each of diildren

THE NEXT QUESTIONS ARE ABOUT YOUR USE OF HEALTH CARE SERVICES

59' At what age do you plan to take your baby to the dentist for the first tirne? - age in years - 1 dont know

60. Has a public health nurse visited you in your home sincc your baby was born? - no - yes -> How many times have you seen her? tirnes

How useful did you find the visit(s)? - very useful - somewhat us& - not usefd

61. Has a public health nurse called you since your baby was born? - no - yes -> How usefd did you find the c d ?

- very usefd somewhat usefd

- no t usefd

62. Have you been to any You and Your Baby or Weil Baby Drop-In groups offered by the Health Department?

- no -> Did you know about them? - no y e s

- yes -> How useful did you find these groups? - very usefui - somewhat us&

no t us&

63. Did you c d the Parent Baby Information Line at the Health Department?

- no -> Did you know about Parent Baby Information Line? -y= n o

- yes -> How useftd did you find the c d ? very useful somewhat useful not useful

64. Have you attended any other activities or &op-ins with this baby? - no - Y= -> Which ones did you attend?

music s-g/gym drop-in/ playgroup discussion groups library group O ther

FLNALLY, A FEW QUESTIONS ABOUT YOURSELF

60. Were you a srnoker in the month before you became pregnant with your youngest child? - no - Y=

66. Did you smoke after the fourth month of your most recent pregnancy? - no - Y-

67. Did you start smoking (again) after your youngest baby was barn? - no (Go to question 68) - Y=

68. If yes, How old was your baby when you started to smoke again? - weeks old

69. Does anyone living with you smoke in your home? - - Y=

HAVING A NEW BABY W YOUR HOME REQUIRES A BIG ADJUSTMENT. IT IS NOT UNUSUAL FOR WOr\rlEN TO FIND THAT THIS IS A DIFmCULT TIME. THE FOLLOWING QUESTIONS ARE ABOUT HOW YOU FELT IN THE LAST M o m

In the last month, how often have you looked forward with enjoyment to things? (interviewer to read responses) - Never - AImost never Sometimes F a i r i y often V e r y often

In the last month, how often have you felt that you were able to controI the important things in your Me? (interviewer to read responses)

- Never - Aimost never Sometirnes F a i r i y often - Verv often

In the last month, how often have you been anxious or womed for no good reason? (intenriewer to read responses)

- Never - Sometimes -Fairly often V e r v often Ahost never

In the last month, how often have you felt confident about your ability to handle your personai problems? (interviewer to read responsesj

- Never - Alrnost never Sometimes F a i r l y often V e r y often

Would you describe your Iife in generai as...

- very stressful - fairiy stressfui - not very stressfui - not at ail stressful

Do you have someone you codd tafi to if you needed help or had a problem? - no - Y S

76. What was the last year you cornpIeted at school, college or university? - public school - grade - highxhool- grade - some colIege - some UNversity - completed college - completed University (one degree) - postgraduate degree

77. Were you born in Canada?

- no -> How many years ago did you arrive in Canada? - l e s than one year - one to two years - three to four years - five or more years

- Y-

78. What Ianguage(s) are spoken at home? (check d that appIy)

- engiish - vietriamese - pu-zjab - fiench - arabic - s o d - chinese - i talian - pohh - spanish - lao tian - ge;;ri;ari - portuguese - cambodian - o t k r (specify)

79. What is your current marital status? married/common law singIe/never married separated

- divorced - widowed

80. Are you (1s the chiid's mother) presently working and eaming money? - no (Go to Question 83)

- yes -> When did you (she) begin to work after the baby's birth? weeks or months

I

1s this work outside the home? no (Go to Ouestion 83) yes -> What childcare arrangements do you have for your baby/other

children under age 5? (ask about baby first, then other chüdren)

Baby Other chüdren Iicensed home daycare - daycare centre - - babytitter's home - - parents share 33dcare - relative provides care - father provides care - -

babysitter in your home - 0th~(speafy) - -

What do you usuaIIy do if your chiid is sick or if the usual chiidriare arrangements are not availabie?

stay home £rom work - mouier - partner famiIy member cares for cMd fxiend or neighbour cares for child other (specrfy)

Has work or planning to go back to work influenced the way you feed your baby?

I dont work or pIan on working outside my home - no

yes - If yes, please specify

At this tirne, what is your total family income before taxes? I'U read the ranges for you. - Iess han $15,000 - $15,000 to 19,999 - $20,000 to 25,999 - $25,000 to 29,999 - $30,000 to 34,999 - S5,OOO to 37,999 - $38,ûûû to 49,999 - $50,000 or more - 1 don? know - I'd rather not s a y

85. How many addts and how many cfüldren are supported with this incorne? number of aduits number of diildren -

86. Are there any programs or services which you think would help you care for your baby? - no - Y= -> Please desaibe what these senrices wouid be.

87. Are there any programs or services which you think would heIp your partner or main support person care for the baby? - no - yes -> Please describe what these services would be.

88. 1s there anything you would like to tell me about Hedth Department programs?

89. For our records is this your correct address? (read off printout) If not what is your address? (indude postal code) We will analyze data by area of city. (make any corrections on label)

Thank you for participating in the study.

ndix 7 - 1996 Infant Care Survey #ANT CARE SURVEY, 1996

INTERVIEWER: READ ALL BOLD TYPE

Mother to answer questions

1. 1 would like to begin by asking how many ehildren are living with you? - child(ren)

2. What are their birth dates? (Eldest to Youngest)

Month

Child 1

Child 2

Child 3

Child 4

Child 5

Y ear

THE REST OF THE QUESTIONS WILL FOCUS ON YOUR YOUSGEST CHILD.

3. Was your youngest baby a boy or a girl? Boy - Girl

1. Where was your baby born? - In Hospital: Civic

General Grace Montfort Riverside

At Home

5 . What type of birth did you have? Vaginal Caesarean

6 . How many weeks pregnant rere you when your youngest child was born?

7. What was your baby's birth weight?

- lbs - o u gram

HOW long did YOU stay in hospital after the birth of your youngest child? 151

Hours or Days

9. How did you feel about the length of stay in hospital after the birth of your baby? Was it:

Too short OK Too long

Please, state the reason for your answer

10. In generai, how bas the baby's health been since he/she was born? Would you Say it has been:

1 Excellent 2 Good 3 Fair 4 Poor 5 Very Poor

1 1. Has your baby had any significant health problems?

Yes (please sptci9)

12. Io general, how has m r health been since your baby was born? Would you Say it has been:

1 Excellent 2 Good 3 Fair 4 Poor 5 ~ e j Poor

13. Have you had any help from family or friends sinee you came home from the hospital with the baby?

1 Yes 2 NO --> GO TO QUESTION #17

I f YES, Who has given you help?

1 Husband/common-law spouse/boyfnend 2 Family member(s), SpeciQ

3 Friends 4 Other (please specie ody

if not f h l y or fiiends)

What type of help have you received? (Please indicate al1 that apply)

1 Assistance with baby care 2 Financial assistance 3 Assistance with house keeping , meal preparation 4 Assistance with care of other children 5 Assistance with personal care (for mother) Please do not add other

Do you feel you had enough help in caring for your baby after he or she came home from the hospital?

Yes No

would like to ask you a few questions about Health Department servires vou ma!* have had since your babv was born.

Has a public health nurse visited you in your home since your baby w a s born?

1 Yes-> How many times have you seen her? times

How useful did you find the visit(s)? /Read responses) 1 Very useful 2 Sornewhat usefiil 3 Not useful

2 No-> Has a Public Health Nurse called you?

y Yes --> How old was your baby when she first called you? d a y s pr - u-eeks

How many times did she cal1 you? times

How useful did you find the call(s)? (iniervie wer read respomes) 1 Very useful 2 Somewhat usehl 3 Not usefûi

- No

153 18. Have you been to one of the Well Baby Drop-ins offered by the Health Department?

1 Yes -> Where was the group you attended? (Write the name of the street herej

How many times did you attend the drop-in?

How useful did you find these groups? 1 Very useful 2 Somewhat useful 3 Not useful

2 No -> Did you know about the drop-ins? 1 Yes 2 No

19. Have you ever heard of the Parent Baby Information Line at the Health Department? (Be sure it is the Health Deportment Iine)

1 Yes --> Have you ever called this Information Line? 1 Yes -> How many times did you cal1 the line?

How useful did you find the call? (read responses) 1 Very useful 2 Sornewhat usehl 3 Not useful

3 No 2 No

20. Did you attend one of the Breastfeeding Support Croups held by the Public Health Department?

1 Yes Where was the group you attended? ( W d e the street narne here)

How useful did you find this group? 1 Very useful 2 Somewhat usehl 3 Not useful

2 No Did you know about these groups? 1 Yes 2 No

Did you receive an invitation in the mail inviting you to attend the groups for new mothers offered by the AeaIth Department?

154

1 Yes 2 No

In the same package, did you receive the pamphlet on "The Birth of a Baby is a Time of Joy: Then Why am 1 Feeling so Sad?" from the Health Department?

1 Yes If yes. how useful did you find this pamphlet? 1. Very usehl 2. Somewhat useM 3. Not usefbl

2 No

Did you receive a pamphlet on "Feeding your Baby €rom Birth to One Year"?

1 Yes I f yes, how useful did you find this pamphlet? 1. Very usefbl 2. Somewhat useful 3. Not usehl

2 No

Did you receive a pamphlet on Choosing and Using Child Safety Seats?

1 Yes If yes. how useful did you find this pamphlet? 1. Ve- useful 2. Somewhat useful 3. Not useful

2 No

Did you receive the fact sheet "Welcome to a Smo ke-Free Home"?

1 Yes If yes. how useful did you find this fact sheet? 1 . Very usefbl 2. Somewhat useful 3. Not useful

2 No

Did you receive the fact sheet "Why Choose Smoke-Free Child Care"?

1 Yes If yes, how useful did gou find this fact sheet? 1. Very useful 2. Somewhat usehi 3. Not useful

1- you a few questions about how o u are feeding vour

155 27. When did you decide to breast or bottle feed your baby?

- Before pregnancy - During pregnancy - After the baby's birth

28. Was breastfeeding discussed with you during your pregnancy?

- Yes --O> Who discussed breastfeeding s i t h you? Physician Prenatd instructor Friend who has breastfed Other(speci@)

- No, breastfeeding not discussed - Don't recall

29. How were you feeding your baby in the hospital? (check one)

Breastfeeding (go to next question) Bottle feeding (skip to question 32) Both (go to next question)

30. Why did you decide to breastfeed your baby? (inten-iewer co categorise)

Do not read oprions Better for me Better for my baby More convenient Better for the family Less costly Other - specify

For how many months did you initially plan to breastfeed?

Less than 1 month 1 or 2 months 3 or 4 months 5 or 6 months More than 6 months No sprcific time

ALL MOTHERS

156 32. Did you or your baby have any medical problems that kept you from feeding your

baby the way you had phnned to?

- Yes (GO TO QUESTIOS 33) - No (GO TO QUESTION Z4)

33. I f YES, please explain

MOTHER

O wound infection jaundice

34. How are you presently feeding your baby?

1 Breastfeeding ody ---> GO TO QUESTIOS =37 2 Breastfeeding with less than 1 bonle a day ---> GO TO QUESTION #36 3 Breasdeeding with 1 bonle or more a day ---> GO TO QUESTION #36 4 Bonle feeding only ---> GO TO QUESTION =35

5 . For how long did you breastfeed your baby?

- Days - Weeks - Months - Never breastfed ---> GO TO QUESTION a 6

36. How old was your baby when you started feeding formula?

Day s - Weeks - Months

37. Did you stop drinking milk or eating dairy products while breastfeeding?

- No - Yes - If yes,---> Why did you stop?

38. Did anyone pdvise you to stop drinking milk?

- Yes - I f yes,-> W h o advised you to stop? (Do nor read options) - physician - fnend - Public Health Nurse - mother-in-law - mo ther - other (specie)

FOR MOTKERS WHO ARE NO LONGER B E A S T FEEDNG, ASK QUESTIONS #39 & #40

39. Why did you stop breastfeeding? (PROBE: Please tell me al1 the reasons you decided to stop).

1 Thought baby was not getting enough milk 2 Cracked or sore nipples 3 HadtogobacktoworWschool 4 Didn't feel comfortablddidn't enjoy breastfeeding 5 Mother was too tired 6 Other (Please specify)

40. Which of these reasons was the most important reason you stopped breastfeeding? (Only indicate one reason)

1 Thought baby was not getting enough milk 2 Cracked nipples 3 Had to go back to work 4 Didn't feel comfortable/didn't enjoy breastfeeding 5 Mother was too tired 6 Above answers equally important 7 Other (Please specifi)

GO TO QUESTION #46 .

41. (FOR MOTHERS WHO ARE CURRENTLY BREASTFEEDING) How long do you pian to breastCeed your baby?

1 plan to bredeed until my baby is weekdmonths old.

42. How rvould you describe the support given by hospital staff for breastfeeding?

- Fair Good ExcelIent Poor

43. Did you receive free formula from anyone?

- Yes -> If yes, Did you receive it from? - hospitai - dot tor

mail - nutrition class

other - NO -> GO TO QUESTION M5

44. When did you use the formula?

Never First 2 weeks 2 weeks - 2 months Mer 2 rnonths

45. Did you breastfeed any of your other babies?

No. this is my first baby No, 1 bottle-fed my other baby(ies) Yes, 1 breastfed - babies

IF BOTTLE-FEEDING OR PAR.TIALLY BREASTFEEDING

46. What formula or milk are you presently feeding your baby?

1 Commercial infant formula 2 Cow's milk 2.1 Whole milk

2.2 2% 2.3 Skim 2.4 Evaporated milk 2.5 Other (Please speciQ)

47. When did you start feeding this to your baby? daydweeks of age

48. Did you feed any other formula or milk to your baby?

- Yes -> If yes, What other formula or milk did you use? 1 Whole milk 2 2% 3 Skim 4 Evaporated milk 5 Other (Please specify)

FOR ALL MOTHERS

49. Have you ever fed your baby any liquids or solids other than milk?

1 Yes 2 NO -2 GO TO QUESTlON #5 1

50. I f YES, please tell me each food (or drink) other than milk that you have fed your baby. At what ege did you first introduce this food or drink.

Food or Drink Age of Baby in Weeks

5 1. Are you giving or did you give your baby vitamin or fluoride supplements?

- Yes --> If os. What supplements are you giving? - Tri-vi-sol - Tri-vi-sol with fluoride - D-vi-sol - Tri-vi-fluor - Poly-vi-sol - Poly-vi-fluor - Other - (specifj)

52. Do you now or have you in the past put your baby to bed with a bottle?

160 - Yes --> If yes, What is or was in the bedtime bottle? - Mik - Water - Juice - Cereal and milk - Other (speciQ)

- No

53. Has your baby had hisher first needles yet?

54. At what age do you plan to take your baby to the dentist for the first tirne?

- Age in years - 1 don? know

55. Are you planning to retum to work?

55a. 1 Yes --> How old will your baby be when you return to work? weeks or months

2 No ---> GO TO QUESTION #57

55 b. (if breastfeeding) Are you thinking about continuing to breastfeed? 1 Yes 2 N o

56. Who will care for your baby when you return to work?

- Da? care centre - Lklicensed home based day care - Licrnsed home based day care - Relative - Partner - Sanny

1 would like to askvou a few uestions about infant safety.

57. Has Four baby had an accidentlinjury where s/he bad to be taken to the emergency department?

- NO -> GO TO QUESTION #59 - Yes --> I f yes, What was hislher age at time of accidentlinjury? -, weeks

58. What happened?

- Fa11 inside home - Something fallhg/spilling on baby - Injury outside home - Ingestionfpoisoning - Motor vehicle accident - Other

59. Does or did your baby use a walker?

60. When you are driving in a car (including taxi-cabs), how often is your infant in an approved car seat and buckied up? (This includes any tirne ever in a car since birth) 1 Always 2 Alrnostallofthetime 3 Sometirnes 4 Not very often 5 Never 6 Don't drive 7 Don't drive with baby in car 8 Other (Please Explain)

6 1. Which way does your infant car seat face when the baby is in it?

1 Forwards 2 Backwards

62. Have you ever been advised about car seat safety?

1 Yes 2 NO --> GO TO QUESTION #64 8 Don't Kn~tviDon't Remember --> GO TO QUESTION $64

63. If YES, by whom were you given this advice? {Circle al1 rhat apply)

1 Public Health Nurse 2 Prenatal class teacher 3 Hospital staff 4 Physician 5 FriendRelative 6 Other (Please specify)

k vou a few auestions about where vour brbv sleeps. . -

Do you have a crib for your infant?

1 Yes 2 No

Would you tell me where you got your crib?

1 Borrowed fiom fnend or relative --> 65a- How old is your ctib? --> GO TO QUESTION #67

2 Purchased -> GO TO QUESTION #66 3 Other (PLease specify)

Have you purcbased a brand new crib?

1 Yes 2 No -> How old is your crib?

Have you ever been advised about checking your crib for safety?

I Yes 7 No --O> GO TO QUESTION $69 - If YES, by whom were you ad~ised?

1 Public Health 'Iurse 2 Prenatal c tass teacher 3 Physician 4 Relativefiriend 5 Pamphlet 6 Other (Please specify)

69. Does anyone living with you smoke?

- No - Yes If yes who? 1 partner

2 mother 3 father 4 other farnilp member. please speciS 5 other, please specie

70. For each of these people, do they smoke in your home?

1 partner 2 mother 3 father 4 other family member. please speciQ 5 other, please s p i @

71. Have you smoked more than 100 cigarettes in Sour lifetime?

1 Yes (smoker. ask next set of questions) 2 NO -----> GO TO QUESTION +82

72. Did you smoke at aU while you were pregnant? (This includes time before you found out you were pregnant)

Yes - (smoked during pregnancy) On average. how many cigarettes did you smoke?

cigarettes per day cigarettes Der week

Y . cigarettes per month ---> GO TO QUESTION #73

No - (did not smoke during pregnancy) ---> GO TO QUESTION #78 Not applicable ---> GO TO QUESTION #78 L'nknowdCan't remember RefiisaiNo answer

ASK IF SMOKED DURING PREZNANCY

73. Did you try to quit durhg your pregnancy? 164

If Yes, What made you try to quit smoking during your Yes --> pregnancy?

74. Have you smoked

Yes

75. Are you currently

al1 since you had the baby?

smoking?

Yes (ASK QUESTIONS 76 AND 77)

No Are you planning on starting to smolie again? - Yes

No ---'

Wbat is making you think about smoking again?

GO TO QUESTION =S2

76. Have you tried to quit smoking since you had your baby?

1 Yes ---> How many times have you tried to quit smoking for at least 24 hours since you had your baby? = = of times

2 No 7 Not applicable

77. a. Are you seriously considering quitting within the nert 6 months? 1 Yes 2 No 3 Don't know

b. Are you planning to quit in the next 30 days? t Yes 2 No 3 Don't know

--> GO TO QUESTION #82

ASK IF DID NOT SMOKE DURING PWGNANCY

When did you quit smoking?

1 Before getting pregnant 2 Uhile you were pregnant (SpeciQ month of pregnancy) months 3 After delivery (Specify weeks after de1 ivery) weeks 4 Other (Please specify)

a Have you started to smoke again?

If yes When did you start to smoke again, days after delivery, What made you decide to start smoking again?

GO TO QUESTION #80

If no Are you planning on starting to smoke again? - Yes No What is making you think about smoking again?

GO TO QUESTION #82

Have you tried to quit smoking since you had your baby?

1 Yes ---> How many tirnes bave you tried to quit smoking for at least 24 hours since you had p u r baby? = + of times

2 Xo 7 h'ot applicable 8 CnknowdCan't remember 9 RefbsaVNo answer

a. Are you seriously considering quitting within the next 6 months?

1 Yes 2 No 3 Don't know

b. Are you planning to quit in the next 30 days?

1 Yes 2 No 3 Don't know

NOIV 1 WOU!^ 1 ke to aok vou a few B a l avsbons aboatyourselfand vo ur baby. As you have recently had a baby, we wodd like to know how you are feeling now. Please Say the 166 annver which cornes ciosest to how you have felt in the past 7 days, not just how you feel today.

MTERVIEWER TO SAY "IN THE PAST 7 DAYS" BEFORE EACH QUESTION.

1 have been able to laugh and see the funny side of things: (interviewer tu reud respomes)

1 As much as I always could 0- 2 Not quite so much now 1- 3 Definitely not so much now 2 4 NotataII 3-

1 have looked forward with enjoyment to things: (interviewer tu read respomes)

1 As much as I ever did 0- 2 Rather less than 1 used to 1- 3 Definitely less than 1 used to 2 4 Hardly at al1 3-

1 have blamed myself unnecessarily when things went wrong: lintervie wer to read responses)

1 Yes, most of the time 3- 2 Yes. some of the tirne - 7 3 Not very often 1- 4 No, never 0-

1 have felt worried and anxious for no very good reason (interviewer fo read responses)

1 No, not at al1 2 Hardly ever 3 Yes, sometimes 4 Yes, very ofien

1 have felt scared or panicb for no v e q good reason. (interviewer [O reod responses)

1 Yes, quite a Lot 2 Yes, sometimes 3 No, not much 4 No, not at ail

Things have been getting on top of me: (interviewer to read responses)

1 Yes, most of the time 1 haven't been able to cope at d l 3 2 Yes, sometimes 1 haven't k e n coping as well as usual 2 3 No, most of the time 1 have coped quite well 1- 4 No, 1 have been coping as well as ever 0-

1 have been so unhappy that 1 have had difticulty sleeping: (intenie wer tu reud responses)

1 Yes, rnost of the time 3 2 Yes, sometimes 2- 3 Not very ofien 1- 4 No, not at al1 0-

1 have felt sad or miserable: (interviewer tu reud responses)

1 Yes, most of the tirne 3 2 Yes, quite oftefi 2- 3 Not very often 1- 4 No, not at al1 0-

1 have been so unhappy that 1 have been crying: (inrerviewer IO reod responses)

1 Yes. most of the tirne 3 2 Yes, quite ofken 2- 3 Only occasionally 1- 4 NO, never 0-

The thought of harming myself has occurred to me: (inteniewer ro read responses)

1 Yes, quite ofien 3- Ask if a P m c m cal1 2 Sornetirnes 2- Ask if a PHN can cal1 3 Hardly ever 1- Ask if a PHiV can cal1 4 Never 0-

TOTAL SCORE

(A score of 12+ indicates mother may have postpartum depression. Ask: It sounds as though you have been feeling down over the past few weeks. You may waot to call your Doctor to discuss these feelings). If they do not have a doctor. advise to call Parent Baby Info Line 724-4 1 79. Thanks for answering these questions on your feelings. 1 know some of the questions may seem a little strange, but some women do experience . problems feeling down after the birth of their baby.

92. What is your date of birth?

93. What was the last year you completed at school, college or university?

- No forma1 schooling - Public school- grade - -Hi& school- grade - - Some college - Some university - Completed college - Completed univenity (one degree) - Graduate or Postgraduate degree

94. What was the last year your partner completed at school, college or university?

- No formal schooling - Public school- grade - - High school- grade - - Some college - Some university - Completed college - Completed university (one degree) - Graduate or Postgraduate degree - I don't have a partner

95. Where were you born?

- Canada --> GO TO QUESTION #97

- Caribbean ---> GO TO QUESTION #96 - Germany - Greece - Holland - Hong Kong - India - Italy - Lebanon - Mainland China - Poland - United Kingdom (England, Scotland, Wales. Sorthem Ireland) or Ireland - United States of America - Other, SpeciQ

What year did you first immigrate (corne to live) to Canada? (year fm immigrated to Canada)

What is your mother tongue (the language you first learned)?

- English - French - Other (SpeciQ)

What language do you speak at home now?

- English - French - Both - Other (SpeciQ)

What was your approximate family income from al1 sources, before taxes during the previous year - January 1,1995 to December 31,1995?

- Less than $20,000 - $2 1,000 to $29,999 - $30,000 to $39,999 - $40,000 to $49,999 - %50,000 to $59,999 - $60,000 or more - Refused to answer fread each response brrr not rhis one)

What is your present marital status? Are you:

1 ~Married 2 common-law 3 Single 4 Separated 5 Divorced 6 Widowed 7 Other (Please speciQ)

Do you have any other comments you would like to make?

102. Date of Interview -- Day Month Year

THANK YOU FOR TAKING THE TIME TO ANSWER THESE QUESTIONS

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