Herein, we describe the perceptions, beliefs, and experiences of the 22 participants in regard to how they fed (or planned to feed) their infants and young children around the following thematic areas: beliefs about healthy eating, common feeding practices, drivers of food choice, and suggestions for improving early feeding education and resources offered by clinicians.

Beliefs about healthy eating

Across groups, women described home cooked foods, fresh produce, and certain cooking methods (grilling, baking, steaming or boiling) as being healthy. Many mothers also talked about the need to have a balanced diet and meals including items “from each food group…making it colorful, at least two vegetables, protein, a little starch.” Mothers in two groups felt that organic foods and certain “superfoods” (e.g., avocado) were particularly healthy. On the other hand, mothers agreed that processed foods (e.g., chicken nuggets, pizza rolls), sugary, fried, or fatty foods, Southern/Soul foods, pasta, produce that is not fresh, and an unvaried diet were unhealthy.

Common feeding practicesStrategies for encouraging healthy eating

Participants described several methods to help their children eat healthier including swapping less healthy foods for something they viewed as more nutritious. For example, one mother takes the cheese off pizza, another participant swapped fried chicken nuggets for grilled at a fast food restaurant, and another mother served sliced, fried ham in place of bacon. Several mothers fib to their small children about these food swaps, for example by saying frozen yogurt is ice cream or giving their toddler raisins in an M&M bag. Mothers justify these untruths as follows: “When he gets older he’s going to be so used to the habit that he’s not going to care anymore, he’s just going to keep eating raisins and be like okay I don’t want M&Ms. This is what I’ve been eating, this tastes good.” Similarly, participants frequently select varieties of commonly used foods that are labeled as organic or “100% natural.” Many mothers gave their kids 100% fruit juice without dyes or artificial sweeteners, while other mothers selected organic bacon (“it’s less grease”) or organic frozen pizza bites. Mothers also stressed the need to control what others feed their children by preparing foods for visits to grandparents’ homes or times with babysitters and finding shortcuts to make using healthy foods easier (e.g., freezing fruit for smoothies).

Mothers in all groups described how their child wanted to eat the food from the mother’s plates. Because of this, mothers felt it was especially important they try to model healthy eating in front of their children. One mother described how her child did not eat certain foods until she started eating them: “She would not too much budge on eating vegetables and drinking water until I transitioned [to eating healthier].”

Use of "unhealthy" foods

Even so, many mothers admitted to including unhealthy foods in their kids’ diets as special treats, to save money and time, and for the family’s enjoyment. Mothers also admitted to occasionally using sweets or other foods as tools to keep kids calm or because their children liked them. For example, one participant shared: “I give her apple juice … and they told me [no] apple juice because of her new teeth coming in but she loves her some apple juice.” Furthermore, ease often trumped healthy eating for the mothers, with participants reporting that “a lot of times” they decided to cook something quick or pick up fast food, as this conversation shows:

R4: But you know I would like to, you know say give my kid a salad, … like she said a vegetable, a starch and then you know chicken or something healthy. But you know sometimes with that you know with working a lot it’s hard to do all of that.

R6: Best laid plans for sure.

Some mothers rarely use pre-packaged foods, while others used them often to save time and because they are easier. Some participants described mixes and precooked foods as cooking from scratch, so the actual consumption of processed foods might have been more common than reported. Furthermore, even mothers that previously stated they only served fresh and healthy foods, frequently used convenience foods like freeze-dried yogurt bits, Cheerios, or cereals puffs as snacks or to occupy children so they could get other things done.

Mealtime experiences

How mothers described meal experiences varied from generally calm to organized chaos, and participants try different techniques to make mealtime smoother (e.g., putting a child’s foods in separate bowls or allowing kids to have food from the mother’s plate). The majority of participants cooked meals for their children six days a week with one day off when they would eat pizza, leftovers, or some other prepared item. When situations allowed food choices for the child, the mothers provided young children parameters to help them make suitable choices. For example, a mother shared the following: “For the most part if it’s something we have and it’s something that is okay to eat then yes he gets to choose um but sometimes he wants you know a popsicle for breakfast so that’s obviously a no.”

Eating schedules were very structured for some families, while others described how every family member ate separately at different times of the day. Families with erratic schedules varied eating times substantially from day to day. The father’s schedule largely dictated whether a family ate together, whereby fathers who work at night or had different diet patterns ate when they wanted but if the father is home for dinner, everyone ate together. In all groups, mothers reported a shift away from requiring that kids clean their plates, instead allowing children to dictate the quantity they ate and not feeling concerned when children ate less food.

Introduction of complementary foods

While some mothers waited for the okay from their pediatrician or nutritionist to begin offering foods other than breastmilk or formula, other mothers made this decision on their own. One reason for choosing to supplement was the perceived need of the child to have certain items (e.g., two mothers gave their young infants water because “everybody need water”) or eat more (“crying for more and more”). Another reason for supplementing early was a feeling that the baby was advanced for his or her age: “My child he was already eating solid foods, beans, rice when he was two months old, for the fact that he was born with [front] teeth.” Some mothers decided to supplement their baby’s diet because they were excited or anxious to see how their child responded to the new foods or wanted to add more variety to their child’s diet. Several mothers let their child’s perceived desire for other foods guide them, starting supplemental foods when their baby showed interest in the mother’s food, “cued” them that it was time for other foods (“When that breast milk isn’t enough then I’ll be like okay [laughter] time for food”), or as a treat or a tool to calm their young baby (e.g., giving a baby under 1 year chocolate milk because she “loves it” and “she’s just quiet” when she has some).

Drivers of early child feeding practices

Several factors influenced mothers' decisions about early childhood feeding (Fig. 1). Mothers explored the experiences of trusted sources but often relied on instincts to decide how and what to feed their children. As one mother said, “So I would just take a little from everybody. My thing is always, what my mother would always tell me when I was pregnant, listen to what your instincts tell you because that helps a lot more during parenting than what other people are saying.”

Fig. 1

Major influencing factors on child feeding practices of mothers

Maternal instincts

The strongest driver of early child feeding practices is mothers’ instincts about what is right for their child. As was highlighted in examples above (mothers giving infants water and the mother feeding solid foods to her two-month old), mothers felt strongly that they knew above everyone else what was right for their child, and they were willing to disregard expert advice that contradicted their views. Further, mothers were disinterested in advice that did not allow for exceptions because many believed their child to be that exception. Even for acute but minor health issues, mothers often gather information from others and the internet before or instead of talking to their doctor or taking a doctor’s advice. One mother described how she “didn’t like the answer my doctor, the precious doctor gave” regarding her daughter’s constipation “so I got home and done my own research and kind of fixed it on myself.” In another case, two mothers specifically ignored the doctor’s advice regarding the use of breastmilk as a treatment for pink eye, with one mother stating: “You have to be informed. I don’t think we just need to take evidence based medicine.”

Social networks

Mothers’ social networks include not only in-person contacts such as family and friends but also virtual communities. Participants valued the advice of other mothers (their mother, mothers in their peer-group) particularly. Many participants listed their mothers as a primary source for information on child feeding and child health, even though some participants felt their parents had some outdated views or practices and blamed their parents for spoiling their children by letting them eat whatever they wanted. Generally, participants valued personal experiences over expert advice, even for medical issues. For example, one mothers said, “You know when they tell you to give your baby this amount of Tylenol, you wanna know like from somebody else that gave their baby that amount of Tylenol. How’d that go? Were they allergic, you know was that too much? Not enough? Like I like personal opinions.”

Among parents of young children, online resources and digital social networks are a vital part of information gathering. Participants across groups reported belonging to private, invitation-only mothers' groups on Facebook and read articles on nutrition and childcare linked by friends or appearing on their Facebook feeds. For some participants, these online groups developed into in-person friendships. Other trusted sites for information on their child’s health include Babycenter (mentioned in three groups), Pinterest, WebMD, Mayo Clinic (each mentioned in two groups), and the CDC, the “American Association for Pediatrics” [sic, might mean the American Academy of Pediatrics], and individual pediatrician’s websites (discussed in one group).

Mothers use online resources when they have a question, want to learn more, need to find something out when the doctor’s office is closed, learn how things are done in other settings (e.g., in other states or outside the USA), research before a doctor’s visit, or discuss topics. Participants described doing a Google search first when researching a topic, calling Google their “best friend,” “the modern day Jesus,” and “good ‘ole doctor Google.” Mothers bookmarked their favorite sites and visited them repeatedly. Participants would not rely on just one online source, instead visiting multiple sites and supplementing that information with discussions with other mothers before making a decision. Participants also used online sources to provide justification for their opinions and decisions, “you just want that um security to make sure that okay I’m doing the right thing. You look it up and see how many other people agree or maybe there’s an article written on it or something.” Several mothers seemed to remember information gathered online better than what they are told by clinicians; for example, one mother learned to dilute juice from online blogs written by other mothers and “probably the doctor told me.” On the other hand, sometimes mothers felt pressure and guilt from social networks, particularly from online communities, for not always making healthy food choices, or what other community members think are the “right” healthy choices, for their children. As one mother said: “it’s like and you think doing so good and then they’re like well that’s not organic eggs.” A few participants even avoided online communities because they felt they were “judgy” and needed to “stay out of my business.”

Trust in online sources varied, although the majority of mothers reported being open to what they read online, trusting online friends “by instinct,” and not crosschecking things if they “seem plausible.” Many participants believed that the veracity of online information is based on the number of people agreeing with it and not by the source of the information. One mother described this as follows: “I gotta see it being consistent, and I have to like actually see how many people are visiting it, how many people were starring it, and stuff like that. Then I know what’s accurate, and what most people experience.” Although a few mothers reported double-checking “facts” by doing online research, across all four groups, only one participant reported trusting a website (cdc.gov) because the information was based on research.

Advice from experts

As described above, participants generally followed their instincts and are less or not likely to ask the pediatrician for advice about diet. For most participants, their doctor’s advice ranked behind that of mothers in their network, and women were split about if they would follow their doctor’s or their parent’s advice if they had opposite opinions about their child’s health. When asked specifically about child feeding, some mothers stated that they do not view nutrition to be a topic that needs to be discussed with their healthcare team: one mother stated she had not spoken to her child’s pediatrician about a food-related concern because “it’s something normal because a lot of kids don’t like vegetables so I it wouldn’t be something that would concern me.” Even among the participants who read and keep materials given to them by their doctor’s office, none spoke about returning to handouts for nutrition information, revisiting them only for developmental milestones and medication information. Several participants reported a reluctance to admit to their pediatrician when they did not follow their advice.

Even among mothers who preferred trusted medical sources like their pediatrician or a well-regarded local children’s hospital website, they still explored additional resources to find “alternatives” and get “second opinions.” Mothers followed a doctor’s advice most often when they had established trust with their pediatrician. This trust is usually developed over time or when the healthcare practitioner listens to the participant and respects her role as mother instead of the doctor being “more into their opinion than yours as a parent.” Participants particularly valued physician relationships where they “don’t feel wrong to ask anything.”

Suggestions for improving patient resources

When providing feedback on existing handouts/pamphlets on early child feeding, mothers shared more about how advice from clinicians should and should not be presented. Participants were most receptive to messages that they agreed with, and they had the most negative comments when the advice contradicted their experiences, opinions, or expectations. For example, one mother shared: “they’re like don’t put cereal in the bottle so it’s like okay so what do you want me to do? Let my baby cry? …. my baby is like 3 or 4 months and I put cereal in his bottle and it worked.” Mothers were split between wanting to get as much information from their provider as possible (“I don’t think anybody is gonna complain about getting an extra sheet of paper if it’s about their baby.”) and feeling overwhelmed by the amount of handouts and advice provided (“I need to know what I’m supposed to do. What’s good for her, what’s not good for her. Like am I underfeeding her? Overfeeding her? Straight to the point.”). Mothers were particularly open to messages that target specific areas of concern.

Participants were very discouraged by negative language and the directive tone of some of the handouts: “I see ‘do not,’ ‘never,’ ‘do not,’ ‘never,’ ‘don’t,’ ‘don’t,’ ‘avoid,’ ‘avoid,’ it it seems very negative … It seems very strict.” Mothers felt that this negatively shut down discussion, while more positive messages encourage the mothers to talk openly with their clinicians, empower the mother, and do not undermine the mother’s role as gatekeeper for decisions around caring for their child. Mothers were often discouraged by the rigidness of the guidelines as well, because children develop differently and advice on feeding and other issues should reflect the developmental stage of their child and not just age. Guidelines also seemed capriciousness: “Um I guess she’s allowed to have milk today [on her baby’s birthday]… I don’t know two weeks ago if her stomach would be any different.”