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. 2017 Jul 21;14(1):e12473. doi: 10.1111/mcn.12473

“Those who care much, understand much.” Maternal perceptions of children's appetite: Perspectives from urban and rural caregivers of diverse parenting experience in Bangladesh

Nurun Naila 1, Baitun Nahar 1, Monica Lazarus 2,7, Gaelen Ritter 7, Muttaquina Hossain 1, Mustafa Mahfuz 1, Tahmeed Ahmed 1,5, Donna Denno 3,4, Judd Walson 3,4,5,6, Scott Ickes 2,5,7,✉
PMCID: PMC6865878  PMID: 28730705

Abstract

Appetite in children is an important determinant of nutritional intake and growth. The information used by caregivers to understand children's appetite can help inform infant and young child feeding promotion and appetite assessment. We conducted a qualitative study to (a) explore maternal perceptions and responses to children's appetite and (b) to identify how these factors differ by type of caregiver, level of maternal experience, and urban versus rural context. We used purposive sampling to recruit mothers and alternate caregivers into 14 total focus group discussions (six to eight participants in each group; N = 95) in both urban and rural settings in Bangladesh. To understand children's appetite, caregivers monitor children's dietary patterns, emotional signs, and physical and verbal cues. Healthy appetite was observed by willingness to eat diverse foods, finish offered portions, and by acceptance of foods without excessive prompting. Child illness was cited for a cause of low appetite, which was manifested through fussiness, and avoiding commonly consumed foods. Mothers described a limited set of feeding practices (offering diverse foods, playing, and cheering children with videos) to encourage consumption when children lacked appetite. Mothers' stress related to work was noted as a barrier to identifying appetite cues. Urban mothers described a lower access to instrumental social support for child feeding but informational support than mothers in the rural setting. Understanding caregivers' perceptions of children's appetite may inform strategies to improve responsive feeding and tool development to assess changes in appetite as early indicators of change in health or nutrition status among high‐risk children.

Keywords: child appetite, childhood illness, hunger, infant and young child feeding, maternal perceptions, South Asia

1. INTRODUCTION

Undernutrition contributes to 3.1 million child deaths annually among children under 5 years (Black et al., 2013). Children in South Asia bear 40% of the global burden of stunting, and over a third of children in this region are stunted because of chronic nutrition deprivation, poor sanitation practices and conditions, and inadequate infant and young child feeding (IYCF; Aguayo & Menon, 2016; Smith & Haddad, 2015). The ability of caregivers to provide adequate nutrition to young children is dependent on multiple factors, which span from the socio‐political context to intrapersonal factors at the level of the mother. Immediate influences of child feeding practices include the availability of household resources, the health and hygiene environment, and the caregiving environment. The latter includes factors such as psychosocial stimulation (Stewart, Iannotti, Dewey, Michaelsen, & Onyango, 2013). The domain of nutritional caregiving includes caregiver's active response to the child's desire to eat according to predictable patterns, known as responsive feeding (Black & Aboud, 2011; Bentley, Wasser, & Creed‐Kanashiro, 2011). Appetite is a psychological desire to eat, associated with sensory experiences related to food such as visual or olfactory aspects, cognitive and emotional cues, and social situations and cultural conventions (Anderson, 1996). Lack of or reduced appetite, known as anorexia, is associated with poor weight gain and stunted linear growth in infancy, as well as IYCF practices (Brown et al., 1992). Reduced appetite is related to acute illness and systemic inflammation, both of which are common in low‐income countries (Prendergast & Kelly, 2012). In these settings where high rates of undernutrition and poor water, sanitation, and hygiene infrastructure coexist, it is important to understand caregiver's awareness of children's appetite to maximize the opportunity to better plan, deliver, and evaluate interventions directed to address children's nutrition and common childhood illnesses.

Perceptions of a child's appetite are important factors in child feeding as they influence the frequency at which caregivers feed children and the amount of food offered during feedings (Black & Aboud, 2011; Bentley et al., 2011). Combined with traditional beliefs and a lack of appropriate knowledge regarding IYCF practices, a perceived or real lack of appetite has negative influences on appropriate complementary feeding (Paintal & Aguayo, 2016). Although child age, peer group, feeding styles, beliefs, and food diversity are known to influence children's appetite (Bentley, Black, & Hurtado, 1995), we lack a solid understanding of how mothers understand appetite cues, and whether and how they recognize changes in children's appetite in relation to overall health or illness. Children in resource‐limited settings often suffer frequent infections (Liu et al., 2015). Beyond the common childhood illnesses of pneumonia, diarrheal disease, and malaria, many children in impoverished contexts suffer from environmental enteric dysfunction (EED)—a condition of subclinical intestinal inflammation, blunted intestinal villi, and increased intestinal permeability. The aetiology of EED is not fully known but is thought to be partially due to chronic intestinal infections and/or chronic asymptomatic exposure to faecal organisms resulting from poor water, sanitation, and hygiene (Keusch et al., 2013). The systemic inflammatory response unleashed by EED, together with the immune activation from other childhood illnesses, is thought to play important roles in increasing metabolism, which inhibits normal bone growth, decreases appetite, and leads to poor growth (Korpe & Petri, 2012).

Current tools available to understand appetite in low‐income countries settings have only been developed in the context of severe acute malnutrition (WHO, 2016). These tools require health worker assessment and are therefore labour intensive. We currently lack a method for accurate and field‐friendly measurement of child appetite in both individual clinical and population‐based community settings. Therefore, it is necessary to improve identification of children who would benefit from interventions directed towards the causes of low appetite and to monitor children's response to interventions. In order to build evidence for how caregivers interpret children's appetite in low‐resource settings, we conducted a qualitative study to (a) understand maternal perceptions and responses to children's appetite and (b) to identify how these factors differ by child age, type of caregiver, level of maternal experience, maternal employment, and by urban and rural context.

Key messages.

  • Caregivers mainly recognize “appetite” in young children through monitoring food consumption and to a lesser extent, the presence or absence of normal food preferences. The main emotional or behavioural signs monitored by mothers are children's food preference or refusal.

  • Child appetite is a well‐recognized concept in Bangladeshi culture; however, there are distinct and important differences in the perception of appetite between urban and rural mothers.

  • More experienced mothers appear to have a better understanding of children's appetite and appear more likely to recognize cues of appetite and anorexia, whereas mothers involved in demanding formal work were described as less aware of children's appetite cues and relied more on alternate caregivers to respond to feeding cues.

2. METHODS

2.1. Participants and setting

2.1.1. Study setting

We conducted 14 focus group discussions (FGDs), six in a rural setting, and eight in an urban setting in Bangladesh. IYCF practices in Bangladesh have improved steadily in the past 10 years but remain poor. Nationally, only 23% of children 6–24 months are fed a “minimally acceptable diet”—a composite indicator of child feeding adequacy that includes the frequency of feeding and dietary diversity (NIPORT, Mitra, & Associates, and IRC Macro, 2016).

Both urban and rural areas were chosen for this study to broaden the generalizability of the study findings. The urban setting, Mirpur, is located in Dhaka and has a population of approximately 500,000 residents in an area of 14 km2 (35,000/km2; Ahmed et al., 2014). This community was selected as the urban setting because it is inhabited by low‐ and middle‐income families, and the residential and sanitary conditions are typical of a congested urban slum settlement. The study investigators also have ongoing research activities in this area, and the urban FGDs were conducted in a preexisting feeding centre. The rural site, Mirzapur, is located approximately 75 km from Dhaka. It is a subdistrict located in the Tangail District of Dhaka Division and has a relatively lower population density of 1,091 residents/km2. Approximately half of the households use improved sanitation, 60% of the population has electricity, and the residents rely mainly on tube wells for drinking water. Men are mostly engaged in rice and jute production or daily wage labour, often abroad, whereas women work mainly in the home (Das et al., 2013). The rural FGDs were conducted in a field office of the International Centre for Diarrheal Diseases, Bangladesh (icddr,b).

2.1.2. Participants

We adhered to the Consolidated Criteria for Reporting Qualitative Research (Tong, Sainsbury, & Craig, 2007). We recruited mothers and alternate caregivers of children between 6 and 59 months to ensure that most children were receiving complementary foods. Data collection occurred in two phases. The first data collection phase recruited FGD participants into groups on the basis of characteristics that the study team believed to be important factors for child appetite. In this phase, we conducted 12 total groups, six in the urban setting and six in the rural setting. Within each setting, we further broke groups down by the age of the child and caregiver experience. Within each site, child age (6–12 months, 13–24 months, and 25–59 months) was used as a group characteristic to account for the different developmental stages of children in relation to how appetite was demonstrated to caregivers. To investigate differences by caregiver experience, two focus groups in each site were composed: one consisting of experienced mothers—that is, those who had more than one child—and one with first‐time mothers. To explore whether mothers' employment status has any effect on understanding or recognizing their children's appetite, we conducted two additional focus groups in the urban setting among mothers who were employed outside of the home. We did not conduct a FGD of this same group in the rural setting as mothers in this context are mostly work full‐time at home are caregivers. The breakdown of focus groups and inclusion criteria for each is summarized in Table 1. Though mothers are still thought to be the primary arbitrator in determining feeding responsibilities (Troiano, Briefel, Carroll, & Bialostosky, 2000), changing maternal employment trends have led to an increasing involvement of alternate caregivers (Chao & Rones, 2007). In Bangladesh, 32% of ever‐married women are employed (NIPORT, Mitra, & Associates, and IRC Macro, 2016). Finally, one group in each site was composed of alternate caregivers, which included fathers, aunts, and grandmothers. This group was recruited by screening households through door‐to‐door visits within each study setting. To be eligible, alternative caregivers were required to be adult who provided full or part‐time child care to a child ages 6 to 59 months who was eating foods in additional to breast milk. Fathers and paternal grandmothers (i.e., mother‐in‐laws to children's mothers) were specifically recruited because they are known to be key decision‐makers for child health in this context (Shahabuddin et al., 2016). Each focus group consisted of six to eight mothers and/or alternate caregivers (N = 95). The data collection was conducted between June 2016 and February 2017.

Table 1.

Summary of focus group sampling strategy and recruitment

Group characteristics Inclusion Criteria Number of Groups
Mothers with children 6 to 59 months Mother of at least one child ages 6 to 59 months 6 (3 urban, 3 rural)
Experienced mothers Mothers of children 6 to 59 months who have at least one previous child 2 (1 urban, 1 rural)
First‐time mothers Mothers who are caring for their first children, ages 6 to 59 months 2 (1 urban, 1 rural)
Mothers working outside of the home Mothers employed at least 20 hours per week in work outside of the time and who live full –time in the Mirpur community. Must have worked for at least two months prior to interview and be caring for a child 2 years or younger. 2 (1 urban, 1 rural)
Alternate caregivers Fathers, grandmothers, aunts, of children 2 (both urban)
Total 14
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2.2. Study tools and procedures

2.2.1. Tools

The conceptual framework of the study (Figure 1) was used to inform the research question, develop the FGD guide, and to guide the analysis. The research team created this framework early in the research process to inform the sampling plan and questionnaire development. This framework describes the proposed basic, underlying, and immediate influences of caregiver's recognition of children's appetite and is based on the WHO Conceptual Framework on Childhood Stunting, which focuses on community, societal, household and family influences of inadequate complementary feeding practices (Stewart et al., 2013). Examples of immediate influences include whether grandmothers, aunts, or hired caretakers are the main participants in child feeding, the number of previous children cared for by a mother, and the level of instruction a mother has received on treating or feeding sick children. Underlying influences include the work and time‐related constraints imposed by work and other caring responsibilities, mothers' experiences in urban or rural settings, and norms around feeding (i.e., the timing of the introduction of complementary foods, typical child feeding styles). Basic influences include women's empowerment, opportunity structure in their surrounding society, educational attainment, and agency. Empowerment is defined as the process by which mothers gain control over the factors and decisions that shape their lives (World Health Organization, 1998). Agency refers to the capacity of mothers to act in their given contexts (Crocker & Robeyns, 2009). Collectively, these factors are expected to exert an influence of mothers' knowledge, attitudes, and beliefs about child appetite, which comprise their perceptions of appetite. Examples of caregiver time include maternity leave policies, commuting time, and type of work. The geographic context is broadly defined in Bangladesh as urban or rural. The household context and family structure refers to the size of the household and presence of alternate caregivers. The cultural norms of child care and feeding include factors such as normative breastfeeding and complementary feeding practices and styles, and caregivers concern over growth and thinness.

Figure 1.

Figure 1

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Conceptual framework of multi‐level influences of caregiver perceptions of child appetite in low‐ and middle‐income countries

2.2.2. Recruitment

The research team has a longstanding relationship with the study communities and maintains a listing of households that include demographic information. Using this register, we identified households in Mirpur and Mirzapur that contained participants who fit the eligibility criteria. Field staff visited eligible participants at home and explained the study objectives. Potential participants were asked if they would be willing to attend a FGD about caregiver experiences with understanding appetite in young children. Eligibility criteria for the study were (a) having a child 24 months and under (for mothers); (b) providing substantial child care for a child under 24 months (for female alternate caregivers) or 5 years (for fathers); and (c) being a full‐time resident in the community of the study setting. We used a higher child age eligibility for fathers to increase the likelihood of recruitment of this group. For the FGD among working mothers, participants were required to be engaged in formal employment outside of the home for at least 20 hr per week for at least 2 months preceding the date of the interview. The day, time, and location of the FGD were confirmed 1 day before the discussion. Participants were briefed about the benefits, privacy, and confidentiality of the study. After obtaining written informed consent and separate permission to audio record the interview from each participant, a research assistant administered a verbal demographic survey with each participant. FDGs lasted approximately 90 min and were all led by the same moderator in Bangla. The focus group guide (Supplemental Table 1) focused on the key topics of interest: (a) words and phrases used to describe appetite; (b) physical and emotional cues/signs/symptoms used to describe appetite; and (c) maternal factors that influence awareness of cues. Participants were provided compensation to cover travel costs and wage loss incurred during participation in the FGD. All study procedures were approved by the International Centre for Diarrheal Diseases Research, Bangladesh (icddr,b) Institutional Review Board. The University of Washington Institutional Review Board provided a waiver, as affiliated researchers only interacted with de‐identified data.

2.3. Data analysis

Interviews were audio recorded, transcribed verbatim in Bangla, and then translated into English. Participants were noted in interview transcripts as P1, P2, and so forth. Interview transcripts were uploaded into Dedoose qualitative data analysis software (Dedoose Version 7.0.23, 2016;) and double coded by two trained qualitative researchers (redacted for review) who developed the codebook with the principal investigator of the study. Agreement of any discordant codes was achieved through discussion, with any final arbitration by the main analyst (SI) as needed. Direct quotes were extracted from interviews and linked to the demographic data using the de‐identified participant identification number. Codes were developed from the conceptual framework (Figure 1) and through emergent themes. The different participant groups were analysed using the constant comparative method using both explicit and implicit processes (Glaser, 2008). Explicit comparisons were made when one participant group remarked on their identity in that group (e.g., first‐time mothers and working mothers). Implicit comparisons were analysed by comparing main themes between groups (e.g., urban and rural) to identify differences in main findings, including the absence of patterns. For example, if participants in the rural group did not describe the influence of maternal employment on appetite recognition when that topic was assessed, we understood this topic to be less influential on mothers' appetite recognition in this setting, compared to the urban context where it was discussed in depth in multiple groups.

3. RESULTS

Table 2 summarizes the demographic characteristics of the study sample. Approximately N = 95 participants (mothers and alternate caregivers) participated in the study, with 41 from the rural site and 54 from the urban site. Education levels among mothers were lower in the urban setting. Among urban mothers, 25% had no formal education compared to just 3% in the rural setting. Urban mothers were more likely to be formally employed outside of the home (44% vs. 6%); however, we oversampled formally employed mothers in the urban context to explore the influence of maternal work on appetite recognition in this population. Among mothers employed outside of their homes, 50% worked in the garment industry and 21% worked as house workers. The mean age at first pregnancy was 1.9 years higher among rural mothers than their urban counterparts (20.8 vs. 18.9 years). We recruited a similar proportion of primiparous and multiparous mothers in each setting.

Table 2.

Demographic characteristics of study participants (N = 95)

Rural number (n = 41) Urban number (n = 54)
Caregiver age (M, SD)a 30.5 ± 10.6 27.7 ± 9.4
Mothers <18 yearsb 3 (9%) 2 (4%)
Mothers 18–35 yearsb 27 (82%) 43 (90%)
Mothers >35 yearsb 3 (9%) 3 (6%)
Other caregiversa 8 (20%) 6 (11%)
Experience of mother (according to number of children)*
Primiparousb 19 (58%) 25 (52%)
Multiparous (>1 child)b 14 (42%) 23 (48%)
Maternal education (mean years, SE)*
No formal educationb 1 (3%) 12 (25%)
Some or completed primary school (1–5th grade)b 7 (21%) 18 (38%)
Some secondary school (6–10th grade)b 21 (64%) 14 (29%)
Higher secondary school (11th grade or higher)b 4 (12%) 4 (8%)
Maternal occupation
Housewife, homemakerb 31 (94%) 27 (56%)
Working formally outside of the homeb 2 (6%) 21 (44%)
Mother's age at 1st childbirth, years (M, SD) 20.8 ± 4.8 18.9 ± 2.8
Father's age at 1st childbirth, years (M, SD) 29.0 ± 4.7 25.1 ± 4.4
Age of youngest child, months (M, SD) 26 ± 17 26.1 ± 14.4
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a

Calculated using the full sample of participants, N = 95 (rural = 41, urban = 54).

b

Calculated only for mothers, n = 81 (rural = 33, urban = 48).

We identified 15 codes related to six main study topics. Table 3 summarizes these codes by topic and includes illustrative quotes. Major topics arising from the focus groups were as follows: (a) words, cues, and signs used to identify and respond to appetite presence; (b) words, cues, and signs to identify and respond to appetite absence; (c) differences in appetite recognition by caregiver's parenting experience; (d) differences in appetite recognition by urban versus rural context; (e) roles of alternate caregivers in appetite recognition; and (f) roles of urban working mothers in appetite recognition.

Table 3.

Codes, definitions, and illustrative quotes

Code Definition of code Illustrative quote
Words and phrases Words or phrases used to describe signs or cues that a child has an appetite “Appetite and likes are different things. Likings are related to choices in mind but appetite is something of taste or delight in mouth.”—(age 27, two children, rural)
Signs and cues, normal appetite Signs and cues that a child has an appetite “When child eats I understand that he has appetite. Will eat everything I offer and if he continues to eat then I will understand that he has appetite.”—(age 27, two children, rural)
Signs and symptoms Signs and symptoms that a child is lacking an appetite “Doesn't want to eat when it's time to. He is apathetic towards foods. Throws away or spits them when sees food.”—(age 28, two children, rural)
Signs or cues, appetite in illness Signs or cues that a child has an appetite during illness “I feed my child three times a day when he is well. But when he is sick he doesn't want to have one meal. Throws away foods I offer him. When he eats I realize that he has appetite.”—(age 26, one child, urban)
Strategies Strategies that caregivers use to help their children to eat “He sits to have food after switching on the TV. Yeah for feeding him TV is necessary.”—(age 16, one child, rural)
Factors/reasons for lack of attention Factors or reasons that prevent caregivers from responding to children's appetite cues “We cannot sit inside the house all the time with our children. I run a shop where I work. It happens like when it's time to take him shower I have to run to other works I cannot keep a care on his proper timely feeding. He doesn't eat since I cannot care him that much. I try to keep my child clean, give him proper nutritious foods or what he wants to eat. But sometimes due to my engagement in household chores I cannot shower or feed him properly.”—(age 45, six children, urban)
Age differences Difference in caregiver perceptions of appetite according to maternal age/experience “Again some mothers keep their children under someone's care and don't understand that much. Those who became mother at the very young age or remain uneducated cannot understand. Some people in the rural areas leaves child's feeding up to the child's own whim...They (very young mothers) are less intelligent or aware of their responsibilities towards their child. And if there is no elderly person around her who already had raised children, then these young mothers cannot get instructions about their child's feeding.”—(age 24, one child, rural)
Urban/rural differences Difference in caregiver perceptions of appetite according to urban slum versus rural setting “Some mothers from rural area understand less. They cannot take care of their child. [They] neglect their feedings until the child starts to cry.”—(age 28, two children, rural)
Maternal work influences Influence of maternal work on appetite recognition or response to appetite cue “When we drop him off there I leave food with him. When I pick my child up I ask the Centre people whether he had eaten or not. If not, then I bring food from the store or feed him at the house.”—(age 20, one child, urban, working mother)
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3.1. Topic #1: Words, cues, and signs to identify and respond to appetite presence

3.1.1. Words and phrases

Mothers and caregivers used words and phrases such as “taste”, “taste sensation,” and/or “delight in their mouth” to describe children's appetite. The majority of mothers and caregivers perceived children's appetite as a desire to eat or eating food when offered. “I understand the appetite. He eats since he has taste in his mouth. Otherwise he would not eat (Age 48, alternate caregiver, rural).”

3.1.2. Cues and signs to understand and respond to appetite presence

Mothers described signs and cues used by children to indicate appetite, such as “bringing food close to him,” pointing to food, grabbing food from a sibling's hand, asking verbally for more food, crying when hungry, and asking other family members (father, grandmother, and “everyone around”) for food. They described that children too young to verbally express themselves sometimes brought plates to their mothers to indicate appetite. Mothers also noted that a key sign of children's appetite is promptly and regularly eating whatever food is offered, “without any trouble” or challenge. Following a bout with illness, the return of appetite, marked by gradual increased food consumption, was a marker of an improving appetite.

3.2. Topic #2: Words, cues, and signs to identify and respond to appetite absence

3.2.1. Words and phrases

When asked about illness and appetite, caregivers recognized the difference between hunger and appetite. They knew that although their child might be hungry and request food, they still refuse to eat due to lack of appetite. “Sometimes he cried all day long and doesn't eat at all. So I understand that he is hungry but has no appetite for food hence could not eat. He throws away whatever is offered. So he has no appetite (Age 23, one child, rural).” Mothers described that a lack of appetite is indicated when their child is “not hungry,” has “no delight,” or has little “interest” or “need” for food. Mothers also mentioned illness as a reason for a lack of appetite. “When the children do not want to eat, we have to try to feed them. If the child has infection in tongue, that's why he cannot eat (Age 23, two children, rural).”

3.2.2. Cues, signs to identify appetite absence

Mothers indicated that refusal to eat even when force fed, reduced breastfeeding, spitting out food or vomiting, and throwing away food are signs of poor appetite: “My child will start to cry when he is hungry but would not eat even if I try to feed him forcefully, he will spit and throw away food. That's how I understand that my child doesn't have appetite (Age 25, one child, rural).”

Caregivers also understood that lack of appetite could be an indicator for illness and some used it as a cue to seek medical help: “Well, during his sickness he eats a lot smaller amount of food or vomits away. Cries a lot too. He doesn't want to eat all of those foods he normally likes when he is sick (Age 22, one child, rural).” As another mother noted, “My child had fever 2‐3 months ago. I wiped his head to cool down his body. He refused to eat at the morning time (Age 32, two children, rural).”

Mothers described other cues to indicate an absence of appetite, such as a child pretending to sleep or feel sick when offered food. “When he sees I am bringing something for him he starts acting like sleeping or says ‘I will not eat this or will say I feel sick’ just to avoid eating (Age 23, one child, urban).” Mothers also noted that children would at times refuse to eat the same foods on subsequent days, noting that appetite would decrease due to a lack of food diversity. “If a child refuses to eat the same food the next day, then it's assumed that the child has no appetite for that food. (Age 23, one child, urban).”

3.2.3. Distinguishing between appetite and other child behaviours

Opinions varied regarding feeding and appetite recognition, and mothers noted that children cry for many reasons. Most mothers noted that cues such as pointing to food, tugging at clothing, vocalizations, or specific requests helped them to distinguish when children cry because they are hungry. Mothers also described that children sometimes cried in response to force feeding and that an appetite may exist even when they refuse to eat. Other family members who participated in childcare offered assistance in responding to crying children and in interpreting if a child's crying was due to hunger.

Caregivers understood the difference between appetite, which was described as the physical and emotional desire to eat, and expressing food preferences, particularly for favourite foods. However, mothers noted the connection between these terms: Appetite was sometimes built by offering favourite foods (e.g., rice and eggs) or when children would consume these and other preferred foods.

3.2.4. Strategies to improve appetite

Mothers and caregivers indicated that they are able to recognize abnormal eating behaviours and mentioned strategies used to facilitate eating. Strategies included force feeding, offering favourite or sweet foods, encouraging eating through playful conversation, and feeding children the foods they request.

3.2.5. Strategies to improve appetite in working mothers

Although strategies were typically the same from mothers employed outside of the house and mothers who worked at home full‐time, mothers who work outside of the home described the practice of giving daytime caregivers money to buy food from outside of the home and to allow caregivers to feed children's favourite foods when they refuse to eat normal family foods.

3.3. Topic #3: Differences in appetite recognition and response by caregiver's parenting experience

Maternal experience was an important factor in the understanding of appetite cues and eating behaviour of children. We assessed this by recruiting first‐time mothers into a separate group in both urban and rural contexts. More experienced mothers noted that younger mothers became more knowledgeable about appetite recognition and appropriate responses with subsequent pregnancies: “If and when the mother has a second child, then this lacking will not be there because she will understand what is needed to be done. That is, she will have the experience of being a mother (Age 22, one child, rural).”

Older mothers described younger mothers as being busier with chores and work that distract them from attentive feeding. “Sometimes if a mother has a child at a very early age, that is, as a result of early marriage, then she would lack sense needed for taking care of babies. They also won't have the sense if they are uneducated. In many villages, some girls get married and think that their child will eat if he wants to eat and not eat if he does not want to. (Age 24, one child, urban).” As one multiparous mother noted that “Mothers need to stay with children always. Then she will understand if her child is eating or not (Age 30, two children, rural).” First‐time mothers noted that the regularity of observing children's eating patterns was important to recognizing if a child's appetite has changed. Younger, first‐time mothers described their experiences with learning: “Now, I understand and can feed my child small amounts. Now it is clear that the child must be fed timely (25 years old, one child, rural).” Another mother described resistance to receiving advice, irrespective of age or experience: “There are many who don't want to listen to others in this regard. What will happen to her child then? (Age 24, two children, rural)”.

Mothers, including participants in the first‐time mothers group, pointed out “early marriage,” “working mothers,” and “illiteracy” as important factors that contribute to mothers' lack of understanding appetite signs and cues. Respondents noted that mothers with media access, or who receive health information from peer group counselling, nutrition programs, or books are more knowledgeable about appetite.

One first‐time mother explained that mothers in Bangladesh have a range of abilities in recognizing and responding to children's appetites, citing qualities like “patience for feeding the child” and connecting the trait of recognizing appetite with the same trait of “easily understanding beforehand whether their child is going to catch fever or cold.” Noting the connection between experience and comprehension, one first‐time mother remarked that: “Those who care much understand much (23 years old, one child, rural).” In addition, most of the working mothers feel that if they would have given more time to their children, they could understand their children's appetite more. “They [other caregivers] are feeding only three times a day, but if I were available I would have been feeding frequently. But I cannot do that (Age 25, three children, urban).”

3.4. Topic #4: Differences in appetite recognition and response by urban and rural setting

The differences in appetite recognition and understanding were assessed mainly through implicit comparisons between the eight urban and six rural focus groups. We identified three main differences between these two groups. First, financial stress in feeding children was more commonly noted in the urban group, who were also more likely to be formally employed outside of the home. Second, the urban group described more resources that can be used to help address poor appetite such as access to nutrition professionals, TV shows, books, and childcare centres. Third, the urban group more readily connected caregiver education with appetite recognition.

The urban setting provided unique challenges to appetite recognition by mothers. Social support from extended families was limited for urban mothers. Thus, several urban mothers noted that their work schedule interferes with their childcare responsibilities: “I have to go to [my] job, so I bathe my child at evening. My child takes breakfast from 8‐9 am, but I cannot feed him (Age 28, four children, urban).” Mothers mentioned that “if they could provide proper time, their children's interest in food may improve.” By contrast, rural mothers said that “they have other family members to take care of their children (Age 23, one child, rural).” Although family support in the form of contributing to childcare responsibilities was somewhat lower for urban mothers than for rural mothers, knowledge about normative appetite and appetite loss was similar between these participants. Both groups described (a) physical illness as a reason for appetite loss; (b) children's crying being both an indicator of appetite or a lack of wanting to eat; and (c) experience with comparing food consumption to a sibling or a similarly aged child to assess a child's appetite.

3.5. : Topic #5: Roles of alternate caregivers in appetite recognition and response

The perceptions of alternate caregivers were identified implicitly through comments made by mothers and explicitly through two focus groups that included alternate caregivers specifically. The importance of alternate caregivers was identified by mothers in both urban and rural settings who described alternate caregivers as key informants regarding their children's appetite, especially in the case of working mothers. Grandmothers noted their own experience with recognizing children's appetite, because they had been parents themselves. “I understand child's appetite well since I have already raised two children before (Grandmother, age 55, Urban).”

Mothers noted that mothers‐in‐law and older sisters provide “guidance about doing and not doing things” to help children eat. One mother noted that her child eats better from her sister, who had more patience with feeding her child and was able to get her child to eat more, noting that, “It takes a lot of time when I try to feed him, and at some point I get angry (Age 16, one child, rural).”

3.6. Topic #6: Roles of working mothers in appetite recognition and response

Both mothers who work outside of the home and mothers who stay at home full‐time with their children describe maternal employment as a major factor in understanding children's appetite cues. Working mothers describe their practice of discussing children's appetite cues and signs with the daytime caregivers after they return home from work: “Whoever I leave my child with, when I am back from work I ask whether my child ate or not” (working mother, urban).” One mother described that mothers who stay at home with their children may be able to feed children more frequently: “…When a mother is at home all of the time she can feed her child in [regular] intervals. A child who eats three times a day has more appetite than a child who doesn't get to eat three times a day (working mother, urban).”

Most mothers who worked outside of the home expressed dissatisfaction with their need to have other adults provide nutritional care for their children. This was partly due to feeling out of touch with children's feeding patterns or feeling a need to provide treats for children when they return home. “I ask my mother what he ate or what he wants to eat, and I bring those foods home for him (working mother, urban).” Mothers described efforts to compensate for their absence by bringing children favourite foods from outside the home upon their return from work. “If he refuses to eat, I give him whatever he wants to eat. I bring chocolate 2‐3 times a day (working mother, urban)”.

Despite feeling somewhat less informed about children's feeding patterns and appetite cues, working mothers made efforts to stay informed about changes in children's appetite, especially during illness. When working mothers do provide nutritional care in the evenings and on weekends, they describe the same set of appetite signs and cues. Some working mothers would encourage daytime childcare providers to encourage children's appetite through providing money and instructions to daytime caregivers to purchase children's favourite foods, for example, to encourage eating if children displayed lack of interest in traditional family foods. “I cook noodles for my child and milk is always in the house. I also leave some money in case he wants to eat something from the store (working mother, urban).”

The type of mother's work was also found to influence mother's availability to provide care for children at home and influence their knowledge of appetite cues and patterns. “Those who work as a housemaid get very few days off because they have to work every day. Garment workers get at least two days off in week (Working mother, urban).” Mothers engaged in formalized employment in the garment industry expressed some reluctance to request days off from work: “I have to ask my employer that my child has fever, cough ... If that's permitted that happens as unpaid leave ... Most of the people don't take leave because they don't get paid (working mother, urban).”

4. DISCUSSION

Caregiver recognition of child appetite during healthy and ill periods appears to be a critical component of optimal nutritional caregiving. Through assessing the perspectives of mothers and alternate caregivers from a variety of backgrounds, this study sought to understand the perceptions and beliefs of caregivers in Bangladesh regarding children's appetite cues, signs, and behaviour. To date, no study has examined caregivers' understanding of appetite nor examined these factors across maternal experience and work level, in both urban and rural contexts.

Schedule‐related stress as well as changing caregiver patterns to accommodate formal and informal work was identified as an important influences of appetite recognition. Maternal employment appears to be a challenge for consistent infant and young child feeding and highlights the important role of alternative caregivers (especially sisters and mother‐in‐laws) as influencers when implementing nutrition interventions that seek to prevent undernutrition. These findings have implications for how appetite recognition may be improved through interventions, and also highlight that less experienced mothers, and mothers who work, may be less knowledgeable about children's appetite cues and thus less appropriate to survey through an assessment tool of child appetite. A recent study based on the Bangladesh Demographic and Health Survey data found that young, first‐time mothers from rural areas were more likely to have an underweight child (Islam, Islam, Bharati, Aik, & Hossain, 2016). Although the trend of adolescent marriage and corresponding early motherhood is decreasing in Bangladesh (Hossain, Mahumud, & Aik, 2016; Kamal, Hassan, Alam, & Ying, 2015), it is clear that young mothers in this context can benefit from additional health system supports and resources to help improve appetite recognition.

Feeding during illness and recovery is especially important in the South Asian context, where children suffer frequent infection. Optimal IYCF practices during illness and convalescence are essential to avoid further nutrient deprivation as nutritional stores are diverted away from growth towards the immune response (Paintal & Aguayo, 2016). In this study, poor appetite during illness and a reduction in children's communication about their appetite were commonly noted. Mothers described children's refusal of food, vomiting, and crying as the most common indicators of a lack of appetite. Mothers had difficulty in assessing appetite cues during illness and reported challenges to feeding their children when they were sick. Although caregivers responded to a variety of signs and cues when children were healthy, mothers resorted to less healthy comfort foods or fed their children forcefully during illness. Although some studies conducted in Nigeria and Guatemala indicate that force feeding may be less common in developing countries (Bentley, Caulfield, Torun, Schroeder, & Hurtado, 1992 and Oni et al., 1991), this feeding style was described by many participants. Undesirable feeding styles, and methods for improving appetite recognition and response during illness, warrants further exploration.

By assessing perceptions of appetite from a variety of groups, we identified characteristics that may place certain groups at risk. Experienced mothers, and those living in a rural context were found to be more responsive than working or urban mothers regarding children's appetite cues and their overall feeding schedules. A study based in rural Kenya identified caregiver's stress related to work schedules as a critical factor for identifying appetite cues as well as the overall health status of children (Abubakar, Holding, Mwangome, & Maitland, 2011). Thus, efforts to improve appetite recognition and nutritional care among caregivers should recognize the broader social context of caregivers, particularly time stress and competing priorities. Efforts should continue to engage alternate caregivers to provide more complete dissemination of key messages to improve appropriate nutrition care.

The research team is working to develop a multidimensional tool to assess child appetite in LMIC contexts as a way to screen children who have poor appetite and as a way to measure responsiveness to interventions addressing underlying causes of poor appetite. The results from the FGD will be used along with evidence from the existing literature to inform the development of this quantitative tool to assess caregiver perceptions of children's appetites. Table 4 summarizes how these findings help inform the tool development. Briefly, the study findings indicated that children's food consumption, in terms of quantity and frequency, was a major factor in understanding appetite. A variety of signs—mainly verbal and physical—were described by caregivers as indicators of children's desire to eat. Mothers described illness as a cause of poor appetite. Mothers and alternate caregivers described a variety of strategies to build an appetite and to encourage food consumption in children who lack a normal appetite. These findings can be translated into questions that assess appetite in the context of illness, recovery, and in the community context where conditions like environmental enteropathy may impair appetite in children with no detectable physical illness.

Table 4.

The application of focus group discussion findings on the appetite assessment tool

Finding An appetite assessment tool in LMIC should assess …
Mothers describe that children's consumption is a sign of appetite Direct questions on quantity of food consumed
Most mothers understand appetite presence as a positive response to being offered food Whether a child consumes food when offered to her/him
Mothers describe lack of appetite as a consequence of illness and return to appetite with recovery from illness. Recovery and about child appetite in relation to normal eating behaviour to assess aberration from norm, including improvement.
Mothers describe a range of maternal experience in their communities, noting that this general experience influences caregivers perceptivity to changes in appetite Assess how experienced and confident mothers feel in recognizing appetite in their children, e.g., Do you feel that you know enough about your child's feeding habits to feel if their appetite has changed?
Appetite is visible when “child stretches the hand,” points, or grabs for food Assess the ways in which a child physically or emotionally asked for food, as well as how these signs change over time or in response to interventions
Maternal work schedules may limit understanding of appetite patterns Question to assess who the primary person responsible for feeding the child is in order to identify if the respondent has reliable knowledge regarding appetite changes, or if other caregivers may also be suitable informants of appetite levels
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4.1. Limitations

Our study is limited by several factors. First, our study design enabled us to identify main themes by participant group but does not allow us to express the frequency of these themes, or to rank order them according to level of importance. Second, although we compare responses by subgroups, our study resources limited the ability to recruit more focus groups for each demographic stratum. We were therefore limited to two groups by characteristic (first‐time mothers, mothers of children under 1 year, and alternate caregivers). To validate findings regarding working women, we did conduct two additional focus groups among working mothers in the urban setting. Although we attempted to develop broad interview guides that could elicit responses that may be applied elsewhere, the cultural context of the study may not translate to other settings. We plan to use the results from this study to inform a quantitative tool that will be tested and refined in multiple contexts to broaden the contextual validity.

5. CONCLUSIONS

To recognize appetite in children, caregivers in Bangladesh primarily observe food consumption, although they also monitor children's emotional and physical cues. Mothers who work in jobs away from home, but receive help from alternate caregivers, may be less informed about their children's appetite cues. Approaches to improve caregiver's recognition of appetite cues, such as education programs to improve infant feeding responsiveness, should be explored. Measurement of children's appetite remains an important area for identifying illnesses that suppress appetite and, in turn, cause poor growth, or to assess treatment responsiveness.

CONFLICTS OF INTEREST

The authors declare that they have no conflicts of interest.

CONTRIBUTIONS

JW and TA secured funding for the study. NN, BN, MH, DD, TA, JW, and SI designed the study and interview questionnaires. NN, BN, and MM oversaw the participant recruitment and data collection. SI, NN, ML, GR, DD, and JW analysed the data and wrote the manuscript. All authors read and approved the final manuscript.

ACKNOWLEDGMENTS

icddr,b acknowledges with gratitude the commitment of Bill & Melinda Gates foundation to its research efforts. icddr,b is also grateful to the Governments of Bangladesh, Canada, Sweden and the UK for providing core/unrestricted support. The authors thank Tracey Tran for help with editing the manuscript, and for the helpful comments of two anonymous reviewers. The authors thank Shamsun Nahar for moderating the focus groups, and Deluwar Hossain for tabulation of the demographic data. We also thank Tasnia Zia for translation of the focus group transcripts, and Lauren Rice for research assistance in the preparation of this manuscript.

Naila N, Nahar B, Lazarus M, et al. “Those who care much, understand much.” Maternal perceptions of children's appetite: Perspectives from urban and rural caregivers of diverse parenting experience in Bangladesh. Matern Child Nutr. 2018;14:e12473 10.1111/mcn.12473

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