Diet and Nutrition Survey of Infants and Young Children in Scotland, 2011

Chapter 5 Feeding practices

Summary of findings

• The proportion of children who had ever been breastfed was significantly lower in the Diet and Nutrition Survey of Infants and Young Children in Scotland (DNSIYCS) (68%) than in the UK sample (78%), and lower than the Scottish results in the Infant Feeding Survey (IFS) of 2010 (74%). Of those who were breastfed, the majority of children (65%) were not breastfed beyond three months of age. Thirty two per cent had never been breastfed.
• The majority of children in the survey were drinking infant formula at the time of the survey, except in the oldest age group of 12 to 18 months. The majority of parents feeding their child infant formula in the home followed recommendations for preparation, for example, 75% reported making up the formula as needed and 68% used water that had been left to cool for no longer than 30 minutes. When feeding outside of the home however, the majority did not follow recommendations, for example 54% made up formula using cold or cooled water. Results were similar to the UK sample.
• For children aged over 12 months, cow's milk was the drink provided most often to the majority of children (36%), followed by water (19%) and formula (16%). Some children aged over 12 months were given squash (17%), juice (3%) or flavoured water (4%) most often.
• Seventy seven per cent of children were given food other than milk before six months of age, and were therefore not in compliance with the recommendation to delay the introduction of solids to six months.
• Baby rice was the most common first food for children in the DNSIYCS (63%), pureed fruit or vegetable was also popular as a first food (18%). Other foods, such as yoghurt or finger foods were the first food for very small proportion of children.
• Most of the children who ate food other than milk 'almost always' (31%) for 'sometimes' (31%) had the same food as their parents, and 'sometimes' had a different meal to, but prepared by, their parents (49%). A substantial proportion 'never' had the same food as their parents (23%), although this was more common for younger children.
• The majority of children who had food other than milk had eaten a commercially prepared baby or toddler meal (59%). Twenty one per cent of children who had food other than milk had eaten a commercially prepared adult ready meal. These were similar proportions as in the UK sample.
• For those children who had food other than milk, most parents (89%) never added salt to their food.
• Children in the DNSIYCS showed progression with age in ability to drink from a cup or beaker with a spout, to eat finger foods, and to use a spoon. Children aged 4 to 6 months in Scotland were significantly more likely to drink from a cup or beaker with a spout compared to those of the same age in the UK (63% and 47% respectively).

5.1. Introduction

The results presented in this chapter derive from the Computer Assisted Personal Interview (CAPI). This chapter describes the practices used in feeding the children in the Diet and Nutrition Survey of Infants and Young Children in Scotland (DNSIYCS). When describing children's ages in this chapter the age discussed is the age at interview, unless otherwise stated.

Comparisons by age in Chapter 5 were tested at the 95% significance level and only statistically significant differences are highlighted in the text. Comparisons of policy interest in Chapter 5 were also tested at the 95% significance level against the Diet and Nutrition Survey of Infants and Young Children (DNSIYC) UK sample. Again, only statistically significant differences are highlighted in the text.

5.2. Milk and drinks

5.2.1. Breastfeeding

Sixty eight per cent of children were reported to have ever been breastfed, with little variation with age. This is significantly less than the proportion for the UK sample (78%). In the Infant Feeding Survey (IFS) of 2010^[1], 74% of those in Scotland had breastfed initially, which is an increase from 63% in 2005 and 71% in 2000^[2]. Thirty two per cent of children had never been breastfed in Scotland, significantly higher than in the UK sample (22%). For those children no longer being breastfed, the age at which they consumed their last breast milk was three months or under in 65% of cases. A further 18% had their last breast milk between 4 and 6 months. Only a small proportion of those who were no longer being breastfed had stopped at 12 to 18 months (4%).

The DNSIYCS sample included children ranging in age from 4 to 18 months. Hence the older children were likely to be having breast milk less frequently than the younger children, as foods were introduced. As expected, the proportion of children still receiving breast milk at the time of the survey decreased with age from 20% of those aged 4 to 6 months and 22% of those 7 to 9 months to 7% of those 12 to 18 months. In the UK sample, a greater proportion (30%) were still breastfeeding at 4 to 6 months. All children still being breastfed at the time of the survey were breastfed at least once a day. For those aged 4 to 6 months, 46% were fed five to six times a day, with over 32% fed more often than this. For those aged 7 to 9 months and 10 to 11 months, the greatest proportion (over 40%), were fed 3 to 4 times a day, with smaller proportions fed more or less often. For those aged 12 to 18 months who were still breastfeeding, 48% were fed one to two times a day, with smaller proportions fed more frequently. Only 1% of children were reportedly fed nine times or more each day, lower than in the UK sample^[3].

Tables 5.2.1 to 5.2.3

5.2.2. Use of formula

The proportion of children being given any type of infant formula in DNSIYCS at the time of the survey was 88% to 92% for those aged 4 to 11 months and 31% for those aged 12 to 18 months.

Powdered infant formula is not sterile and can become contaminated with microorganisms, which can cause serious illness. The Scottish Government therefore provide guidance about the safe preparation, storage and handling of infant formula^[4]. These are referred to as formula preparation recommendations in this report.

The large majority of parents made up the formula as needed (67% to 83%) in line with recommendations, with 24% of parents of those aged 4 to 6 months and 25% of those aged 7 to 9 months making up several feeds at once. There were lower proportions of parents who reported doing this for children aged 10 months or over. This was similar to the UK sample, although the proportion making up several feeds at once was significantly higher for those aged 7 to 9 months in Scotland. When making up formula, 68% of parents overall used water that had been boiled and left to cool for no longer than 30 minutes in line with recommendations, although 32% used water that had boiled but left for longer than 30 minutes. These results were similar to the UK sample.

Tables 5.2.4 to 5.2.6

When parents were asked about feeding their child infant formula away from home, 16% of those with children aged 10 to 11 months and 27% of those with children aged 12 to 18 months never fed their children when away from home, with much smaller proportions for younger children, similar to the UK sample. Parents of those aged 4 to 6 months were most likely to make up an infant formula feed while away from home, while for the older age groups, the formula feed was more likely to be made up before leaving home (30 to 35%). Overall, 22% were likely to take a ready to feed formula with them when going away from home, similar to the UK sample. For those aged 7 to 9 months, 7% of parents only breastfed when away from home, with small proportions for the other age groups. There were no mothers in Scotland who expressed breast milk when away from home.

For those parents who made up formula before leaving home, the majority did not keep the formula chilled, not in line with the recommendations, except for those aged 12 to 18 months. For those who made up the formula while out, the proportions making up feeds with cold or cooled water (not in line with recommendations) and the proportions making up the feed from hot water (as recommended), either obtained while out of the home or having it in a flask, were similar, and varied by age, but not consistently. In the UK sample significantly more parents made up formula with cold or cooled water when out than in the Scotland sample.

Tables 5.2.7 to 5.2.9

5.2.3. Drinks given most often

For those children who were reported to be given drinks other than or as well as breast milk, the drink most often given to those aged under a year old was infant formula (83% for those aged 4 to 6 months, 60% for those aged 7 to 9 months and 43% for those aged 10 to 11 months). Follow on milk was more likely to be given to children aged between six months and a year (16% for those aged 7 to 9 months and 27% for those aged 10 to 11 months) than the youngest and oldest age groups (5% for those aged 4 to 6 months and 8% for those aged 12 to 18 months). As in the UK sample, the drink given most often to those aged 12 to 18 months was cow's milk (36%), with very small proportions giving this most often in the younger age groups. Twelve per cent of children aged 4 to 6 months were given breast milk most often. This proportion reduced with age to 4% of children aged 12 to 18 months. These figures were significantly lower for those aged 4 to 6 months in Scotland than in the UK sample. Ten per cent and 19% of children aged 10 to 11 months and 12 to 18 months respectively were given water as a drink most often. The proportions given other drinks most often were small; for children aged 12 to 18 months, 5% were given non-low calorie squash/soft drinks most often and 11% were given low calorie squash/soft drinks most often (significantly higher than the UK sample).

Tables 5.2.10 and 5.2.11

5.3. Eating patterns

5.3.1. First foods consumed

The Scottish Government recommends that complementary foods should be introduced at six months of age^[5]. Overall, 99% of children in DNSIYCS had been given food apart from milk, as in the UK sample. Of these, 13% of children had food by three months of age, 30% at four months, 33% at five months, and 21% at six months. A very small proportion of children were given food for the first time aged seven months or over (3%). These are similar proportions to the UK sample. These proportions can be compared to the 2010 IFS Scotland results where 6% of children had received solid food by three months of age, lower than DNSIYCS (13%); 32% by four months in 2010, compared to 44% in DNSIYCS; 74% by five months compared to 77% in DNSIYCS; and 94% by six months compared to 97% in DNSIYCS. There was a noticeable reduction in the proportion fed solid food by four months in the 2010 IFS (32%) compared to the 2005 (60%) and 2000 (83%) surveys. By six months of age, most children had been given solid food in DNSIYC and IFS surveys.

Table 5.3.1

For children who had been fed complementary foods, the most common type of first food was baby rice, this being the first food in 63% of cases overall. Results were similar to the UK sample except that proportions were rather lower for some age groups with a higher proportion of 'other' as the first food. This included rather more instances of porridge or baby porridge than in the UK sample. The second most common type of first food was pureed fruit or vegetables, for 17% of children given their first food at the age of four months, and for 6% of those given their first food aged three months or under. This compared to 14% of those having pureed fruit and vegetables as their first food at three months or under in the UK sample. Other foods, such as pureed or lumpy meat or fish, finger foods or yoghurt were given as a first food to smaller numbers of children, as seen in the UK sample.

Table 5.3.2

5.3.2. Introduction of solids

For children who had been fed complementary foods, 88% were reported to suck or chew on finger foods by 7 to 9 months of age, with a much smaller proportion (54%) of those aged 4 to 6 months. These results were similar to the UK sample. Sixty per cent of children aged 4 to 6 months usually ate smooth pureed food; for older children, much smaller proportions usually consumed their food this way. The majority of those aged 7 to 9 months (72%) and 10 to 11 months (59%) usually ate their food with some lumps, with lesser proportions for those aged 4 to 6 months (39%) and 12 to 18 months (29%). These results are similar to the UK sample although the proportion of those aged 4 to 6 months consuming food with lumps was significantly higher in Scotland. By 12 to 18 months, 70% of children usually ate their food unblended or unmashed, similar to the UK sample. The most common age at which children started having meals with lumps was 7 to 9 months (52%), with 35% starting to have food with lumps aged 4 to 6 months, 9% not until 10 to 11 months and very small numbers at three months or under and at 12 to 18 months, a similar distribution to the UK sample.

For 89% of children overall, parents reported that it was not difficult to introduce solid foods. For the remaining 11% for whom parents did report difficulties, the main reasons given were that the child would not take solids, was disinterested in food, preferred drinks to food, or would only take certain solids. In the IFS, (only provided for the UK as whole), these same four reasons were also common reasons for having difficulty introducing solid foods, although the proportion of children who refused only certain foods was higher in IFS (42%) than in DNSIYCS (25%), where there was a greater proportion not taking solids at all.

For children of all ages, the vast majority of parents indicated that their child was 'often' or 'always' interested in food, 'often' or 'always' had a big appetite and 'never' or 'rarely' took more than 30 minutes to finish a meal, as was found in the UK sample. When parents were asked whether the child was full before the meal was finished, about 40% overall indicated that this happened 'never', 'rarely' or 'sometimes', with little variation with age; 18% indicated that this happened 'often' or 'always', with no trend with age.

Tables 5.3.3 to 5.3.8

5.3.3 Meals consumed

For children who had been fed complementary foods, over 90% of those aged seven months or over ate solid food three or more times per day; for those aged 4 to 6 months, 68% ate solid foods this often. This was similar to the UK sample. At 4 to 6 months, 7% of children eating complementary food 'always' or 'almost always' ate the same food as their parents. This proportion rose steadily with age such that for those aged 12 to 18 months, 67% of children 'always' or 'almost always' ate the same food as their parents, a trend also seen in the UK sample. Conversely 73% of those aged 4 to 6 months 'never' ate the same food as their parents; this proportion decreased with age. However, at aged 12 to 18 months, 6% of children still 'never' ate the same food as their parents.

Thirty four per cent of children aged 4 to 6 months 'always' or 'almost always' ate a meal prepared by, but different from, their parents, 31% for those aged 7 to 9 months. This proportion was lower for the older age groups decreasing to 14% for children aged 12 to 18 months.

For children aged 4 to 6 months, 35% 'always' or 'almost always' ate a commercially prepared baby or toddler meal for the main meal of the day. This proportion steadily decreased with age so that for those aged 12 to 18 months, only 4% 'always' or 'almost always' ate a commercially prepared baby or toddler meal for the main meal. Conversely 29% of those aged 4 to 6 months and 20% of those 7 to 9 months 'never' ate a commercially prepared baby or toddler meal for the main meal, rising with age to 59% for those 12 to 18 months. The proportions eating or not eating commercially prepared baby or toddler food as the main meal were similar to the UK sample. Very few of those 4 to 6 months and 7 to 9 months (1% and 10%) had ever eaten a commercially prepared adult ready meal. This proportion increased with age to 17% for those aged 10 to 11 months and 32% for 12 to 18 months, similar proportions to the UK sample.

For all children in DNSIYCS aged 4 to 6 months, parents had 'never' added salt to their food, including in cooking. This proportion decreased with age but remained high, such that 82% of parents had 'never' added to salt to the food of a child aged 12 to 18 months. Although also high in the UK sample, overall the proportion reporting not adding salt to children's food in Scotland was significantly higher (89%) than in the UK sample (83%).

Tables 5.3.9 to 5.3.14

5.3.4 Foods avoided

For children in DNSIYCS who had been fed complementary foods, 37% of parents overall had avoided giving certain foods to their children, the same as in the UK sample. This proportion increased with age from 14% for those aged 4 to 6 months to 42% for those aged 12 to 18 months. Of those avoiding giving certain foods, the most commonly avoided foods were nuts (42%), followed by all meat, poultry, fish, seafood and offal (35%), all eggs and dairy (26%), spicy foods (25%), sweets and chocolate (22%), and processed foods (18%). These proportions were similar to those for the UK. Other foods were mentioned by smaller numbers, such as salad vegetables, fresh fruit and wheat. Numbers were too small in DNSIYCS to analyse the various reasons for avoidance.

Tables 5.3.15 to 5.3.16

5.4. Developmental feeding practices

The Scottish Government recommends that from six months mothers start to introduce children to drinking from cups and beakers. This helps to reduce bottle use and thereby reduces the risk of tooth decay^[6].

The proportion of children who had ever drunk from a cup or beaker with a spout increased with age, from 63% of those aged 4 to 6 months, rising steadily to 95% of those aged 12 to 18 months. They were similar to the IFS Scottish results, where 62% of children had used a cup or beaker with a spout by six months, compared with 58% in DNSIYCS, and 88% by nine months, compared with 85% in DNSIYCS. For those aged 4 to 6 months, the proportions who had ever drunk from a cup or beaker with a spout were significantly higher in Scotland than in the UK sample (63% and 47% respectively).

For children aged 4 to 6 months who drank from a cup or beaker with a spout in DNSIYCS, the majority (64%) drank this way 'sometimes', with a smaller proportion (24%) drinking this way 'usually'.

Of those children who had been given food other than milk, 42% of those aged 4 to 6 months could feed themselves a rusk or similar food. This figure increased to 87% of those aged 7 to 9 months and 99% of those aged 10 to 11 months and 12 to 18 months, similar proportions to the UK sample. Of those children who had been given food other than milk, 9% of those aged 4 to 6 months could feed themselves with a spoon. This also increased with age to 70% of children aged 12 to 18 months.

Tables 5.4.1 to 5.4.7