Complementary Feeding Practices and Nutritional Counseling: A Cross-Sectional Qualitative Study in Southern Brazil

Study design and ethical considerations

This was a cross-sectional study with a qualitative approach, conducted among parents or legal caregivers of children who had initiated complementary feeding. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki and was approved by the Research Ethics Committee of Universidade Alto Vale do Rio do Peixe (UNIARP), Brazil (protocol no. 7.111.937/2024). All participants provided written informed consent before participation.

Study location and population

Participants were recruited in person through the Mãe Caçadorense Program, a municipal public health initiative associated with the Brazilian Unified Health System (Sistema Único de Saúde – SUS), in Caçador, Santa Catarina, Brazil.

A total of 97 individuals proceeded to eligibility assessment. Forty-six individuals were excluded: 32 were pregnant with their first child, five declined participation, two were unable to provide relevant information about the complementary feeding practices of their child, and seven had children older than the predefined age limit. Thus, 51 parents or legal caregivers met the eligibility criteria and were included in the final analysis. Convenience sampling was used.

Eligible participants were parents or legal caregivers of children younger than 10 years who had already initiated complementary feeding. Individuals who were not parents or legal caregivers, whose children had not yet initiated complementary feeding, or who declined participation were excluded.

Development of data collection instrument

Because no previously validated questionnaire fully addressed the specific dimensions investigated in this study, a structured instrument was developed based on the scientific literature and the objectives of the research. The instrument addressed sociodemographic characteristics, complementary feeding practices, sources of nutritional guidance, introduction of different food groups, and perceptions regarding nutritional counseling.

The content of the instrument was reviewed by six experts, including two pediatricians, one nutrologist, and three nutritionists. The experts assessed the clarity, relevance, and appropriateness of the questions in relation to the study objectives. Based on their evaluations, the instrument was refined before data collection.

A pilot test was subsequently conducted with nutrition professionals to assess the clarity and comprehensibility of the questions and to identify potential difficulties in their interpretation. Adjustments were made before the final version of the instrument was applied.

Data collection

Data were collected through face-to-face interviews conducted by a trained researcher specializing in maternal and child health. The interviewer had no prior relationship with the participants. Interviews were conducted individually in a private setting to ensure confidentiality and minimize potential discomfort.

The structured instrument included questions regarding sociodemographic characteristics, breastfeeding history, the age at which complementary feeding was initiated, foods introduced during complementary feeding, sources of information or guidance, and access to nutritional counseling.

Questions concerning the sources of guidance allowed participants to select more than one response. Therefore, these categories were not mutually exclusive, and the corresponding percentages were calculated independently.

For questions concerning the age at which processed foods were introduced, participants who reported that such foods had not been offered were not included in the calculation of the mean age of introduction. The reported mean therefore represents only participants who provided a specific age at which these foods were introduced.

All interviews were audio-recorded using a smartphone with the participants’ permission. The recordings were subsequently transcribed verbatim, and the transcripts were reviewed for accuracy.

Qualitative data analysis

The qualitative data were analyzed using thematic content analysis. Two researchers independently reviewed the interview transcripts and performed the initial coding. Codes were generated inductively from recurring meanings, concepts, and patterns identified in the participants’ responses. Related codes were subsequently grouped into broader categories and themes.

The researchers compared their coding and interpretations throughout the analytical process. Any discrepancies were discussed and resolved by consensus. The emerging themes were reviewed iteratively to ensure that they adequately represented the participants’ responses and remained consistent with the study objectives.

Data collection and analysis continued until thematic saturation was reached, defined as the point at which no new relevant codes or categories emerged from the interviews.

Participants were identified using pseudonyms in the presentation of qualitative findings to preserve confidentiality.

Statistical analysis

Descriptive statistics were used to summarize the quantitative characteristics of the sample. Continuous variables were presented as means and standard deviations, while categorical variables were presented as absolute frequencies and percentages. For variables involving multiple responses, percentages were calculated independently and therefore were not expected to sum to 100%.

For the age of introduction of processed foods, only participants who reported an age of introduction were included in the calculation of the mean and standard deviation; responses indicating that the foods had not been offered were treated as not applicable to this calculation.

A total of 51 participants were included in the final analysis, ranging in age from 16 to 43 years, as shown in Table 1. The vast majority were female (98.1%) and reported educational levels ranging from completion of the fifth grade of primary school to higher education. The number of children per mother ranged from 1 to 6, with a mean of 2.52 children per mother. The age at which participants gave birth to their first child ranged from 14 to 31 years, with a mean age of 19.65 years at the time of the first childbirth (Table 1).

Of the respondents, 21.2% (n = 11) reported seeking nutritional counseling. However, all those who consulted a nutritionist did so only after having already begun complementary feeding. No participant reported seeking nutritional guidance before starting the introduction of solid foods. Among the most common sources of guidance, participants were allowed to report more than one source of complementary feeding guidance; therefore, the percentages were not mutually exclusive and could exceed 100%. Pediatricians were reported as a source of guidance by 61.5% of participants, family members by 21.2%, and 32.7% reported relying on their own knowledge or initiative. These categories should therefore be interpreted independently rather than as mutually exclusive sources.

In the open-ended responses, several topics emerged related to breastfeeding, the timing and consistency of complementary feeding, and the introduction of processed foods.

Breastfeeding

There is no doubt that breastfeeding is the optimal food for the infant’s first months of life. It provides complete nutrition and various health benefits for the baby, such as protecting the gastrointestinal and respiratory systems against infections, supporting healthy weight gain, being free of contamination, and strengthening the mother-child bond [14].

When asked if they practiced breastfeeding, some mothers’ statements were notable:

“Only at the beginning, then it didn’t work anymore. It wasn’t even two weeks. I got uncomfortable and stopped.” (Bromelia, 2023).

“No, he’s been on infant formula since birth.” (Ixora, 2023)

“Actually, until two months. He didn’t want it anymore, and I didn’t insist too much.” (Cineraria, 2023).

“No. I couldn’t. I did practically everything, but it didn’t work out.” (Chrysanthemum, 2023).

Among the negative outcomes of early weaning and inadequate complementary feeding are impaired growth and reduced quality of life, with greater risk of obesity at any life stage [15]. Some mothers managed to maintain breastfeeding for longer: “Yes. She’s seven months old now and still breastfeeding.” (Hibiscus, 2023).

Alsada et al. (2025) [16] highlighted that current guidelines recommend exclusive breastfeeding for the first six months, continuing alongside complementary feeding up to two years or more. This recommendation is based on the fact that breast milk alone provides all the nutrients infants need, supporting immune function, growth, and psychological development [3].

Breastfeeding offers many benefits for both mother and child, including lower risk of respiratory infections, otitis, diarrhea, and sudden infant death syndrome [17]. Longer breastfeeding duration is also associated with reduced risk of diabetes, overweight, and higher cognitive performance [18].

In this study, 42 mothers reported breastfeeding. The duration varied from one month or less to two years or more. However, only 18 mothers (34.6%) practiced exclusive breastfeeding up to six months, while two mothers reported exclusive breastfeeding but gave water or tea before six months. Ten mothers did not breastfeed at all. These findings align with PAHO (2018) [19], which reports the highest global exclusive breastfeeding rates in Latin America and the Caribbean, where about 38% of babies are exclusively breastfed—similar to the 34% found in this study.

First food offered

Parents were asked what the first food offered to their child was. The most frequently mentioned foods were banana and bean broth (each cited ten times), followed by vegetable soup (eight mentions) and potato (six mentions). The question yielded varied responses:

“Banana.” (Celosia, 2023)

“Yogurt.” (Agapanthus, 2023)

“Fermented milk drink.” (Heliconia, 2023)

“Plain cookie.” (Aster, 2023)

“Beans.” (Japanese Anemone, 2023)

Similar to Vieira et al. (2022) [20], fruits were the most common first food offered, followed by broths and soups. Primary healthcare professionals must guide parents on the correct way to introduce different food groups, ensuring meals include grains, tubers, legumes, animal protein, vegetables, and greens from the start [21].

Although there are no strict recommendations on the frequency of processed foods in infant diets, it is well-established that such products should be avoided in early childhood due to links with non-communicable diseases [22]. Complementary feeding should meet energy and nutrient needs while ensuring proper hygiene, cultural fit, affordability, and respect for the child’s taste preferences [23].

Complementary feeding

Complementary feeding is defined as providing liquids and other foods along with breast milk or infant formula to meet an infant’s nutritional requirements [2,10]. It may follow different approaches: traditional (WHO-recommended), Baby-Led Weaning (BLW), or BLISS (a BLW variation focused on minimizing choking risk and improving iron and calorie intake) [13]

Cultural, socioeconomic, and individual factors influence complementary feeding practices [3]. Signs of readiness must be observed, such as tongue reflex, chewing ability, head control, sitting unsupported, disappearance of tongue-thrust reflex, and gastrointestinal, renal, and taste maturity [24].

Despite recommendations, many parents introduce solids earlier than ideal. In the US, 31.9% start before four months—similar trends appear in the UK, Italy, and Australia, where initiatives aim to curb childhood obesity [25]. In this study, when asked at what age feeding began:

“About three months.” (Christmas Cactus, 2023)

“At two months.” (Lisianthus, 2023)

“At two months?” (Interviewer)

“I was going back to work, but then I didn’t. Still, at two months, he was already eating.” (Lisianthus, 2023)

Some participants delayed feeding: “Around nine months.” (Daisy, 2023); “She started with fruit at seven months.” (Gerbera, 2023). Delayed introduction may also be detrimental, as breast milk alone cannot fully meet energy needs after six months, risking micronutrient deficiencies and growth faltering [26].

Food consistency

Participants described food consistency practices:

“When I started with apple, I would grate it, and I’d mash banana for her — always without sugar. But my mother-in-law added sugar, so I’ll have to talk to her. I prefer something like avocado without sugar — she liked it. Once you start with sugar, they won’t want it plain anymore.” (Rose, 2023)

“I mash it and sometimes do it BLW style.” (Allamanda, 2023)

“I let her handle it herself.” (Dahlia, 2023)

“At first we gave it whole.” (Buttercup, 2023)

The first foods should be mashed, progressing gradually [24]. Vieira et al. (2022) [20] found that 60% used mashed textures, 22.9% purées, 14.3% liquids, and few practiced BLW. This study found similar trends but also noted whole foods being offered from the start.

The WHO recommends starting with mashed foods, not blended, and introducing textures gradually to support chewing and sensory development [21]. However, blending and offering whole foods too early were common here.

Processed foods and ultra-processed foods

The questionnaire used a broad question concerning the introduction of processed foods and included a list of commercially prepared and industrialized food products. For the present analysis, the terminology was revised to distinguish processed foods from ultra-processed foods according to the NOVA classification whenever the classification of an individual food item was unambiguous. Therefore, the term “processed and ultra-processed foods” is used when referring collectively to the foods investigated by the questionnaire, whereas “ultra-processed foods” is used specifically for items classified within this category according to NOVA.

Parents were asked: At what age did you introduce processed foods?

“From six months on. I gave her a processed dairy snack.” (Iris, 2023)

“At five months.” (Perpetua, 2023)

Despite recommendations against early processed food consumption [27], many children consumed these products: “After one year, I couldn’t hold back because relatives started giving it.” (Snapdragon, 2023); “We gave her cookies and instant cereal; sometimes she also gets a bit of cake.” (Amaryllis, 2023)

When asked about a list of processed foods (gelatin, cookies, commercial baby food, pastries, soft drinks, artificial juices, instant cereals, chocolate milk drinks, cake, candy, honey):

“All of them before one year old. The only thing I avoided was soft drinks because of colic.” (Bougainvillea, 2023)

“All of them, except pastries.” (Tulip, 2023)

“She’s lactose intolerant, so not much. But at about one year she started having chocolate-flavored milk drink.” (Cosmos, 2023)

Some parents were more careful: “We never gave those things, even to the older kids. We don’t buy that stuff. This baby won’t eat that either. We know that’s where diseases start. We leave them in the car at the market so they don’t see it and want everything.” (Bleeding Heart, 2023)

Balanced diets rich in minimally processed foods ensure healthy growth [28]. Early exposure to processed foods shapes unhealthy habits lasting into adulthood [1].

Value of nutrition counseling

When asked if professional nutrition follow-up is important:

“I don’t think so. We know enough and family helps.” (Dipladenia, 2023)

“Now that he’s three, maybe. He eats one day, not the next. But for complementary feeding, I didn’t think it was needed.” (Hyacinth, 2023)

“As a baby, not so much. Later in life, maybe.” (Portulaca, 2023)

“Indifferent to me. Maybe.” (Anthurium, 2023)

“I think yes — to check what she eats and her weight; she’s a bit underweight.” (Calendula, 2023)

“If the child is healthy, I don’t think it’s necessary.” (Waxflower, 2023)

“Yes, because she’s already a bit chubby.” (Daffodil, 2023)

“Yes, because I have doubts about what to give, how, and about allergies.” (Pansy, 2023)

“Yes, because he learned what he could eat. I didn’t know, and he had allergies. The nutritionist helped. Also, we need to weigh him for Bolsa Família.” (Daisy Fleabane, 2023)

“Yes. I work with kids and know nutrition is vital, especially for disorders like autism, ADHD, ODD, dyslexia.” (Orchid, 2023)

“When they’re learning to eat, you don’t always know what they can have. It’s better to have guidance from someone who really knows.” (Clivia, 2023)

Families shape children’s habits. Educating them from the first years is essential to expand taste, textures, and healthy choices.

It is important to acknowledge some limitations of this study. Although the instrument did not undergo formal psychometric validation, which represents a limitation, its design was supported by rigorous methodological procedures, including an extensive literature review, expert panel content validation, and a pilot test to ensure clarity, relevance, and appropriateness for the study’s objectives. All data were self-reported by parents or caregivers, which may have introduced recall bias or social desirability bias, especially regarding the timing, type, and consistency of foods offered. Furthermore, the qualitative approach and the specific local context of the participants may limit the generalizability of these findings to other regions or populations. Future research should include larger and more diverse samples, combine self-reports with medical or nutrition records, and consider direct observation methods to enhance the validity and reliability of the results.

Despite these limitations, the present findings contribute to a better understanding of complementary feeding practices and reinforce the need for accurate and accessible nutritional guidance for families, aiming to promote healthy eating habits from the earliest stages of life.

After the child’s sixth month of life, exclusive breastfeeding alone is no longer sufficient to meet all of the infant’s nutritional needs. Therefore, the introduction of complementary feeding becomes essential. However, this process is still surrounded by many uncertainties and misconceptions on the part of parents and caregivers.

The findings of this study showed that most parents did not seek nutritional counseling during the complementary feeding period. In many cases, parents also expressed a desire to make healthier choices in future pregnancies or feeding practices. The primary source of guidance reported was the pediatrician, and in all cases where nutritional counseling was sought, this occurred only after complementary feeding had already begun.

These results highlight the crucial role of nutrition professionals, who have the technical knowledge and skills to guide parents appropriately during this phase. Despite clear recommendations from health authorities and researchers emphasizing the need to build healthy eating habits from early childhood, there remains a lack of deeper investigation into the reasons why families do not always follow this guidance.

It is therefore essential that future multidisciplinary studies seek to better understand the factors that influence infant feeding behaviors in the Brazilian context. Such evidence is necessary to design effective actions and educational programs that are culturally and socially appropriate, aiming to promote lasting improvements in feeding practices and contribute to children’s health and well-being in the long term.

Funding

No grants or other financial support.

Authors’ contribution

Author 1: Conceptualization, Investigation, Writing - Original Draft, Visualization.

Author 2: Conceptualization, Writing - Review & Editing.

Author 3: Conceptualization, Writing - Review & Editing, Supervision. All authors contributed to the article and approved the submitted version.

Disclosure of interest

The authors declare that they have no competing interests.