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Though these findings highlight an important and less-investigated sector of obesity research, there are still many unanswered questions. For example, we were unable to examine in depth the real reasons why each group of women introduced nonmilk foods early. A comparative analysis using in-depth interviews with each group of women to explore the reasons for early introduction could provide useful data in understanding why this high prevalence of early introduction of nonmilk foods exists and persists in this population.

The programmatic suggestions garnered from this study are that healthcare providers need to be vigilant in their assessment of obesity in children, particularly in the O-to-two-year-old group. Recent recommendations from the Obesity Evaluation Expert Committee, indicates that children under two years old who are obese need to be referred to an obesity expert for evaluation and treatment. As far as we could tell during this study, the only referrals made for the participants were to the WIC dietitian for counseling. Surprisingly, in this sample where the majority of the women had constant contact with the WIC dietitian, there was a high prevalence of overweight among children under six months of age—suggesting either problems with the type of counseling they were receiving or a lack of desire to implement what they were being taught. Like Bronner et al., our findings suggests there may be a need for improvement in the nutrition educational approaches utilized by WIC in motivating mothers to comply with national infant feeding recommendations. Some of the improvements that would be beneficial are a focused attempt to initiate intense prenatal education for women during the last trimester of pregnancy, alerting them to the effects of overnutrition on the infant’s adiposity outcome. Messages to women should specifically inform them that infants gain most of their adipocytes in the last three months in-utero and the first six months postnatal, and during these periods, feeding practices which promote an increase in adipocytes’ size and number will impact their children for a long time in diverse ways. These messages should also be delivered and reinforced consistently by all members of the healthcare team. 

Finally, serious consideration should be given to focusing prenatal, infant nutritional education to first-time mothers who have little personal infant feeding experiences and who would, therefore, be less likely to have conflicts leading to noncompliance with the nutritional information given to them by healthcare providers. Specifically targeting first-time mothers would assist new mothers in their immediate infant feeding experience as well as prepare a foundation of feeding knowledge upon which they could draw to benefit subsequent children born to them. Additionally, this approach would also lay the foundation for a new generation of women who in later years would be able to provide sound nutrition counsel to their daughters and other female relatives.


The findings of this prospective study confirmed that maternal perception of infant body size does affect infant feeding decisions. Mothers who perceived their infants as small were more likely to introduce nonmilk foods before two months of age. However, the reasons for this practice were not always based on nutritional reasons.
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By the end of the study, over 31% of the infants in the study had BMI >95th percentile, and a combined 40% were above the 85th percentile, according to NCHS weight-for-height standards. It was also observed that compared to women of normal weight, overweight mothers were twice as likely to underestimate the body size of their infants using the AAIBHS scale, even when the infants were overweight.