Growth and size in infancy matter to parents and professionals. Intervention in infancy has the potential to promote health throughout the life course.¹ Although the benefits (or otherwise) of early interventions may not be realised for many years, the beliefs and behaviours of individual lay persons (in this case, particularly parents) will affect the uptake of policy or interventions immediately. As Harden et al² point out, bringing together views and studies in a systematic way may deepen our understanding of public health issues. Systematic reviews also represent good stewardship in terms of the time of both participants and researchers.

This paper describes a systematic review designed to understand lay (particularly parental) views of infant size and growth.

METHODS

This research was part of a review of scientific evidence on infant growth and health, which included a review of the relationship between infant growth or size and life-course outcomes.^3–5

Combining quantitative and qualitative research in systematic reviews is a developing method.^6,7 Techniques currently used in such reviews,^8,9 alongside guidance from the Centre for Reviews and Dissemination,¹⁰ were used in this review, including independent double reviewing at all stages.

Twelve databases were searched (Medline, PsycInfo, CINAHL, Sociological Abstracts, IBSS, ASSIA, British Nursing Index, ChildData, Caredata, SIGLE, Dissertation Abstracts (US), Index to Theses). The table in the appendix provides search terms, which include terms for size, weight or growth and qualitative methods, views, and opinions or attitudes. Searches were conducted in August 2003 and updated in March 2004 (2852 abstracts retrieved and screened). Subject experts and corresponding authors of included papers were contacted for details of additional studies.

Inclusion criteria were as follows:

• Age: views towards infants aged 0–24 months (including retrospective accounts)

• Publication date: since 1978 (one generation)

• Study focus: opinions, views and attitudes on size or growth of infants

• Methods: qualitative and quantitative studies, including survey of views but excluding studies of food intake alone

• Country: no countries were excluded a priori, reviewers considered relevance of each study to a British context.

Data extraction was challenging for quality assessment and extraction of findings across different study designs. We resolved this problem by extracting data as relevant to this review. Study quality was assessed using a revised checklist for qualitative research.^6,11,12 Quality was judged on appropriateness of design, the extent to which context and setting were accounted for, appropriateness of sampling strategy, participation or response rates, the process of analysis (including triangulation), assessments made of typicality and indication of relevance to policy. Harden et al² have suggested that studies not “rooted” in the experience of the individual should be excluded from systematic reviews of views. We did not exclude, but instead reported, quality assessments alongside study descriptions, and embedded quality assessment in the data extraction process. Reviewers distinguished between directly reported views and author interpretations or quantitative summaries; greater weight was placed on the directly reported views.

Study findings were extracted using the following questions:

1. What is healthy size and growth?

2. How important are size and growth to participants?

3. What concepts are used to define healthy size and growth?

4. How do participants assess normal size and growth?

5. Where does growth lie among priorities for health?

6. What information influences views and behaviour?

7. Who influences views and behaviour?

Two researchers independently conducted thematic analyses, categorising and interpreting extracted data. Relevance, strength and duplication of themes were discussed iteratively until an agreed synthesis was produced that allowed interpretation of all data.

RESULTS

Overview

Nineteen studies (17 papers) were included, representing the views of 3590 individuals from the UK, Canada, Finland and the US. Most of the respondents were mothers (n = 1948), including 276 recruited at the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) clinics for low-income families in the US and 212 mothers recruited because their child was born early, had been admitted to neonatal intensive care or had faltering growth. The sample also included 10 other family members, 16 dieticians, 263 public health nurses, 816 adults from general population samples and 730 children and adolescents (in one study).^13,14

For the purposes of this review, reviewers judged the quality of many studies as low. Few studies reported qualitative data. Table 1 summarises the characteristics and quality appraisal of included studies.

Despite our efforts to find studies elsewhere, all were from the discipline of healthcare, and were often conducted in primary care, by nurses or with mothers of infants with health problems.

Size or growth?

Size and growth have precise and different meanings. However, neither authors nor participants made this distinction explicit. For consistency, we have tended to refer to size alone, except in referring to growth monitoring and faltering growth.

Understanding healthy size

Notions of healthy size were dominated by constructions of normality; “normal” size and development was key for many parents, particularly parents of low birthweight infants.²²

Constructing size norms

Seven studies reported data on how participants assessed or defined normal size.^{13–15,22,26,27,30,31} Four themes emerged with regard to assessment of size:

1. Medical definitions, including the use of growth charts.^26,27,31 “I take her to clinic where they measure her height and her weight. They show me ... what is the normal height for children her age” (WIC mother).²⁶

2. Comparisons with other children in the community.^13,14,22,30 “You just want him to be normal, like everyone else” (mother).³⁰

3. Comparison with family members.^15,26 “She’s just a little below average as far as the children in the family” (WIC mother).²⁶

4. Use of clothing sizes. “If they are not fitting in the clothes they should be fitting in, they’re not average” (WIC mother).²⁶

Explaining size difference

Participants sought explanations for size that differed from normal, including the following:

1. Inherited differences.¹⁵ “I really do believe it is genes”.²⁶

2. Medical explanations, in studies considering children with poor growth.^{15,18,23,29,30}

3. Quality of care.^15,26 “The care, the diet, parents having a lot of love toward their children makes them grow” (WIC mother).²⁶

4. Fatalism: sometimes implicit (eg, heritability) and explicit in one study: “I think that her size is out of my hands” (WIC mother).²⁶

Concerns about size

Participants associated size with health.^23,30 “Unhealthy” size indicated that something was wrong: “we were panicked, we knew something was wrong”.³⁰ Despite this, size itself was not the most important concern, even for parents of small infants.^22,25 “As my daughter was healthy and full-term, I felt too much was made of her weight. If she was having trouble with her breathing, I could understand the concern” (mother, dispenser in pharmacy).²⁵

Participants and study authors viewed feeding and size as complementary^15,26,21,23: “If [my children] are overweight, at least I know they’re eating”.¹⁵ Conversely, if infants were appropriately fed, parents were less likely to be concerned about size. Mothers were more concerned about undereating and avoiding hunger in infants.¹⁶

Other concerns included infant attractiveness and ease of birth of smaller infants.^17,25

Nutritional status of infants was also important. Authors in one study noted half of mothers of children with faltering growth restricted intake of unhealthy food.²³

Size was also a marker of parental competence. Mothers “reported blaming themselves for their child’s poor weight gain, feeling they had not done sufficient to ensure adequate weight gain.”²³ Experience seemed to increase confidence in parents of premature infants.¹⁹

Level of concern about size

Despite low levels of concern about size,¹⁸ a high value was placed on growth monitoring.^27,31 In one study, 85–92% of mothers gave weighing their infant as the most common reason to attend a clinic.²⁷

In a phenomenological study on parents of children with faltering growth, the lack of explanation for growth differences provoked anxiety: “The constant fear with which families lived was all encompassing”.³⁰

Influence on views, behaviour and interpretations of size

Figure 1 (from Brofenbrenner³²) shows the influences as organised by reviewers into a nested model.

Mothers listened to advice and information from close family and friends.^15,18 Wider social networks (relatives and other parents) also influenced mothers,²² but were not always welcome²⁵: “it was so difficult to go out and hear negative things about him...” (mother of child with faltering growth).³⁰

Mothers also listened to health professionals.²³ In a study on midwife support, one mother said of the research midwife: “This kind of support should be available to all women” (barmaid).²⁵ First-time mothers used health professionals more than those with older children.²⁸

Health professionals could also have a negative effect on women’s feelings²⁰: “Frequent weight checks and visits from health visitors [were] constant reminders of maternal inadequacy in producing a baby that was different from ‘normal’”.³⁰ Lack of information from health professionals was frustrating: “I just see them writing down [his weight and height] ... They don’t tell me how much he has grown” (WIC mother).²⁶

Other sources used by participants were pamphlets,²⁸ books,²⁴ magazines, television and radio.²⁷

The studies were reported between 1981 and 2002. None described their historical or cultural context.

DISCUSSION

Principal findings

Notions of what constituted healthy size were dominated by the concept of “normality” reflected in concerns about size, sensitivity to the comments of others and distress when no plausible explanation for size difference could be found.

The data have some contradictions—for example, the contrast between the importance ascribed to growth monitoring and the value given to size alone as a measure of health. Parents may be using growth as a means of assessing unobservable characteristics (eg, good parenting or adequate nourishment). These contradictions may also be due to the limitations of included studies or may reflect inconsistencies in how people understand everyday life.

In contrast with the wish for “normality”, for some there was an optimistic feeling that children were simply going to be the size that they were going to be. Provided infants were well cared for, size was not something to worry about. More powerful than fatalistic notions was the concept of appropriate individual variation. This is important when considering how health professionals communicate concerns about size or growth to parents.

Strengths and weaknesses of the study

An advisory group with backgrounds in public health, paediatrics, infant nutrition, qualitative and quantitative methods, systematic reviewing and including user groups oversaw the study. In attempting to locate and synthesise studies, a wide range of sources was searched. However, the relatively well-developed systems for searching health databases may have contributed to the dominance of studies concerned with health.

Although we restricted the included studies to those from countries that are socially or economically similar to the UK, or which have contributed a large immigrant community to the UK, the studies were largely based outside the UK. Applicability to the UK population or healthcare system would need to be tested.

Research paradigms tend to favour studies of single systems, diseases or social constructs. This can result in a focus on “problematic” individuals, as observed in the included studies. Gaps in the research literature included the views of family members other than mothers (particularly fathers), and comparisons between the views of those who have breast fed, bottle fed or weaned their infants; parents of first or subsequent infants, and of different ethnic or cultural groups. There was a paucity of high-quality qualitative studies, and of studies combining qualitative and quantitative data.

To our knowledge, no reviews of views on early growth have been conducted. Two recent UK studies have commented on parents’ perceptions of weight and overweight in young children,^33,34 although neither included infants (and were therefore not included in this review).

Implications for clinicians and policy makers

The value placed by parents on being like everyone else has implications for health promotion messages. If trends in infant size continue towards greater fatness, “being normal” will include infants who are fatter than those in the past. Conversely, current concern about levels of overweight and obesity may lead to greater awareness and anxiety. The sensitivity of parents to such messages needs to be considered when disseminating research findings about changing norms.

This synthesis suggests some of the routes by which parents are influenced. Policy informed by such research is likely to be more meaningful to parents than simple messages about average size and average effects.