Sachs et al. (2011) claim that most parents are very interested in their child’s growth. However, there is much evidence to suggest that parents are not good at recognising overweight in their own children (Crawford, Timperio, Telford, & Salmon, 2006). This has been demonstrated in a variety of studies in the UK (Jeffery, Voss, Metcalf, Alba & Wilkin, 2005; Carnell, Edwards, Croker, Boniface, & Wardle, 2005), America (Baughcum, Chamberlain, Deeks, Powers, & Whitaker, 2000; Etelson, Brand, Patrick, & Shirali, 2003), Australia (Fisher, Fraser, & Alexander, 2006; Wake, Salmon, Waters, Wright, & Hesketh, 2002) and China (Wen & Hui, 2010). There is also evidence to suggest that the recognition of overweight can be affected by the age and sex of the child. For example, in an American study of the parents of children aged three to ten, Wald et al. (2007) found that older children were more likely to be recognised as overweight than younger children. In relation to sex, an Australian study of the mothers of children aged between two and six years found that the mothers reported more concern over their daughters’ weights in general than the weights of their sons (Crouch, O’Dea, & Battisti, 2007), and it has been observed that overweight is more likely to be recognised in girls than in boys (Wald et al., 2007). Wald et al. (2007) hypothesise that societal standards of attractiveness are more likely to influence the parents of older children, hence why they are more able to identify overweight; and that attractiveness standards are likely to be more rigid for girls, explaining why more girls were recognised as overweight than boys.
Empirical studies have suggested that some parents may have an emotional unwillingness to admit that their child is overweight (Maynard, Galuska, Blanck, & Serdula, 2003), and Chamberlin, Sherman, Jain, Powers, and Whitaker (2002) reported that parents can be offended if such a possibility is suggested to them. Jain et al. (2001) found that mothers described overweight children of either sex as thick or solid. Crouch, O’Dea, and Battisti (2007) have suggested that mothers may often
be able to recognise overt obesity in their children but not overweight, and confusion amongst parents over what constitutes overweight in infants and children has been identified (Pagnini, Wilkenfeld, King, Booth, & Booth, 2007). In the study by Jain et al. (2001) mothers did not consider children to be overweight if they had no limitation in physical activity and were not teased about their weight. There is also the possibility that overweight is becoming normative so parents just do not notice it in their child (Carnell et al., 2005; Crawford et al., 2006).
Even if they do recognise their child as overweight, parents may be unconcerned about this (Crawford et al., 2006). In a qualitative study utilising focus groups with Australian mothers of children aged two to five years, Pagnini et al. (2007) reported that not all mothers thought that overweight was an important issue for preschool children and were reluctant to label this age group according to their weight. Mothers have been reported as thinking that their overweight preschool child would grow out of it by school age (Chamberlin et al., 2002). A perception amongst some parents that a larger infant or child is healthy has been identified (Baughcum, Burklow, Deeks, Powers, & Whitaker, 1998; Chamberlain et al., 2002), that a large infant is a sign of successful mothering (Baughcum et al., 1998), and that it was better to be a little overweight than to be underweight (Pagnini et al., 2007). Pagnini et al. (2007) speculated that this may be an extension of the value often placed on weight gain during the first year of life.
A number of common misconceptions regarding growth charts have been identified and it has been suggested that many parents do not have the knowledge or skills to interpret patterns of infant growth correctly (Ben-Joseph, Dowshen, & Izenberg, 2009; Sachs et al., 2006a). For example, one study found that although the mothers of preschool children could recall the centile position of their child on a growth chart, they could not explain what that meant (Woolford, Clark, Lumeng, Williams, & Davis, 2007). Parents have commented that they found weights recorded in kilos confusing and would prefer to use pounds and ounces (Sachs, 2011). Other studies have indicated that parents are concerned if their child is growing in the bottom quarter of the growth chart and would prefer their infant to be growing along one of the higher centiles (Laraway, Birch, Shaffer, & Paul, 2010; Sachs et al., 2006a). The majority of growth charts have depicted the 50th centile in bold, and this has led some parents to think that growth along this centile was the most desirable (Sachs et al, 2006a; Sachs et al., 2011). In their ethnographic study of women and health professionals’ use and understanding of growth charts for breastfed babies, Sachs
et al. (2006a) found that rather than focussing on actual weight gain, there was an expectation amongst parents that weight would follow the shape of the centiles on the growth chart and that concern was expressed if an infant dipped below a previous centile. All of these findings demonstrate a misunderstanding about what position on the growth chart means. During the recent design of the UK-WHO growth charts, parents were consulted to ensure that the charts and accompanying material made sense to them. This has been described as “unique in the creation of child growth charts” (Sachs et al., 2011, p.438) and may contribute to improved parental understanding of their infant’s growth trajectory.
Inaccurate perception of a child’s weight by parents has significant implications as parents have a central role in preventing childhood overweight and obesity, and interventions to prevent or ameliorate the condition cannot be successful without their involvement (Wald et al., 2007). This is particularly so when children are very young. Relatively little is known, however, about parents’ strategies to prevent overweight (Crawford et al., 2006), or indeed how they ensure that their child is not underweight either. In their study of 1210 Australian families Crawford et al. (2006) found that 31% of parents of 5-6 year olds and 43% of parents of 10-12 year olds reported that they employed strategies to help prevent their child from gaining too much weight. This was regardless of the child’s weight status: the use of preventive strategies was not related to the current weight of their child. Thus, this indicates a concern about overweight, but coupled with the evidence presented above indicating parental difficulty in recognising overweight and obesity, the ways in which this is put into practice are not clear.
Therefore, there is evidence that not all parents accurately understand normal patterns of infant growth or are able to interpret their own infant’s growth pattern as plotted on the growth chart in the parent-held child health record. Combined with research that suggests that parents often find it difficult to recognise overweight in their infant or child, the potential for confusion about what is normal growth and the unwitting ‘allowance’ of the development of overweight in small children is apparent. This is salient background to the current study, as the ways in which mothers understand growth in relation to feeding their very young infants, a group not much studied in this way, is to be explored.