WIC 902 Woman or Infant/Child of Primary Caregiver with Limited Ability to Make Appropriate Feeding Decisions and/or Prepare Food

A woman or an infant/child whose primary caregiver is assessed to have a limited ability to make appropriate feeding decisions and/or prepare food. Examples include, but are not limited to, a woman or an infant/child of caregiver with the following:

• Documentation or self-report of misuse of alcohol, use of illegal substances, use of marijuana, or misuse of prescription medications.

• Mental illness, including clinical depression diagnosed, documented, or reported by a physician or psychologist or someone working under a physician’s orders, or as self-reported by applicant/participant/caregiver.

• Intellectual disability diagnosed, documented, or reported by a physician or psychologist or someone working under a physician’s orders, or as self-reported by applicant/participant/caregiver.

• Physical disability to a degree which impairs ability to feed infant/child or limits food preparation abilities.

• ≤17 years of age.

See Clarification for more information about self-reporting a diagnosis.

Category	Priority
Pregnant Woman	4
Breastfeeding Woman	4
NonBreastfeeding Woman	6
Infants	4
Children	5

A primary caregiver’s ability to make appropriate feeding decisions and prepare suitable food is crucial for the health and nutrition of infants and young children. Infants and children depend entirely on caregivers for food, as well as to learn what, when, and how to eat. A responsive feeding relationship, in which caregivers recognize infant/child cues and respond appropriately in a warm and nurturing environment, is critical for supporting healthy dietary habits, food preferences, and weight outcomes in children (1). Several situations that might impair the feeding abilities of a caregiver have been identified below as potential nutritional risks for infants and children.

A pregnant or postpartum woman’s ability to choose and prepare suitable foods for herself is vital for her own nutritional status and wellbeing. A variety of circumstances can impair a woman’s ability to make diet-related decisions or prepare food and thus have been identified as possible nutritional risks for pregnant and postpartum women.

Substance Use

About 1 in 5 children in the US live with at least one caregiver who has a substance use disorder (2). While little research has been conducted on the impact of parental substance misuse on infant/child feeding, much has been learned about the influence of substance misuse on overall parenting and caregiving abilities. Parental substance misuse is sometimes associated with the following, which can all potentially have a negative impact on infant/child feeding:

• Impaired parental behaviors – “lower levels of parental involvement, limited or absent parental monitoring, ineffective control of children’s behavior, and poor discipline skills” (2).

• Compromised caregiving relationship – Less sensitive and responsive to infant/child’s cues and needs (3, 4); and less warm, positive, nurturing, and emotionally available (5).

• Reduced capacity to prioritize infant/child’s needs (including feeding needs) over need for substances (2, 4).

• Parental difficulty in controlling emotions and anger (4).

• Reduced likelihood for infants/children to receive adequate medical and dental care (2).

• Chaotic, unpredictable home environment – higher rates of household financial instability, food and housing insecurity, inconsistent employment, domestic violence, and stress(2).

• Parental incarceration (2).

• Increased likelihood of infant/child entering foster care – about 60% of infants and 40% of children in out-of-home care are from families with substance use disorders (2, 4).

• Increased risk of neglect and abuse – children of parents who misuse substances are 3 times as likely to be physically, emotionally, or sexually abused and 4 times as likely to be emotionally or physically neglected (2).

In addition to impacting infants/children, substance use can also impair a woman’s ability to choose and prepare suitable foods for herself. People with substance use disorders tend to have impaired decision-making (6, 7), which can extend to diet-related choices. Also, as stated above, substance use can result in difficulty in controlling emotions and anger; a chaotic, unpredictable home environment; and incarceration – all of which can negatively impact ability to choose and prepare foods.

For additional information, please refer to Risk 372 – Alcohol and Substance Use.

Mental Illness

Mental illness refers to a wide range of mental health conditions-disorders that affect your mood, thinking and behavior. Examples of mental illness include depression, anxiety disorders, schizophrenia, eating disorders and addictive behaviors (8). Some caregivers with a mental illness can struggle with parenting, including the feeding of infants and young children (1, 9). Depression in particular has been studied for its impact on the caregiver-child feeding relationship. For mothers with depression, they may be less able to detect and respond to an infant’s needs, including feeding needs. Depressed mothers are also more likely to be withdrawn, disengaged, and non-interacting, all of which can negatively impact infant/child feeding. Maternal depression may also have a significant impact on breastfeeding dyads, as depression is linked to worrying more about breastfeeding and reporting breastfeeding difficulties (10). In addition, mothers who are depressed tend to have decreased rates of breastfeeding initiation, duration, and exclusivity, compared to mothers who are not depressed (10). There is a scarcity of research on the impact of other forms of mental illness (other than depression) on the caregiver-infant/child feeding relationship. For additional information on depression, please refer to Risk 361 – Depression.

Mental illness can be debilitating to pregnant and postpartum women in a variety of ways, which include impairing the ability to choose and prepare suitable foods. Some studies indicate that poor eating habits may be common among those with a mental illness (11, 12). For example, people with bipolar disorder or schizophrenia are more likely to report only eating once a day, eating alone, and having difficulty with preparing food (11). Individuals with a mental illness also may experience cognitive challenges, which can limit learning and retention of information about nutrition and food preparation. In addition, those with a mental illness may also have limited resources (due to not being able to work) for purchasing foods.

Intellectual Disability

Intellectual disability is a disability characterized by significant limitations in both intellectual functioning and in adaptive behavior, which covers many everyday social and practical skills (13). A limited amount of research has been conducted on the impact of caregiver intellectual disability and infant/child feeding. Some research indicates caregivers with an intellectual disability may be less sensitive to an infant/child’s cues (14). Other research indicates some caregivers with an intellectual disability also struggle with interacting positively and demonstrating affection with their infant/child (15). Based on each individual’s situation, these concerns could possibly impair a caregiver’s ability to provide appropriate infant/child feeding.

Having an intellectual disability, such as Down syndrome, may make it difficult or even impossible for women to choose, prepare, or serve themselves foods and beverages (16). As a result, some women with intellectual disabilities are at risk for developing diseases associated with obesity, inactivity, and poor nutrition and may have very little choice in deciding their dietary intake since it may be determined by a caregiver (17).

Physical Disability

Some physical disabilities have the potential to reduce a caregiver’s ability to feed an infant/child appropriately or prepare suitable foods. Likewise, some physical disabilities may limit a woman’s ability to feed herself or prepare suitable foods for herself. This risk should be assigned if a caregiver’s physical disability restricts or limits food preparation ability or ability to feed an infant/child. It should also be assigned if a woman’s physical disability restricts or limits her ability to prepare foods for herself or to feed herself.

17 Years of Age and Younger

In 2015, about 230,000 infants were born to teenage mothers; this is a birthrate of about 22 per 1,000 teenage women (18). Teenage mothers may face several challenges as they raise infants and children, including their ability to interact in a responsive manner. Being a teenage mother is sometimes associated with the following, which can all potentially have a negative impact on infant/child feeding:

Increased likelihood of a compromised caregiving relationship – Reduced verbal and emotional responsiveness to infant/child (19), reduced sensitivity to needs of infant (19), and impaired ability to provide cognitive stimulation to infant/child (20).

• Increased likelihood of infant/child entering foster care (20).

• Greater likelihood to misuse substances (21).

For additional information regarding pregnant and postpartum adolescents, please refer to Risk 331 – Pregnancy at a Young Age.

WIC provides support to women and to infants/children of caregivers with limited ability to make appropriate feeding decisions/prepare food by offering counseling on nutrition, breastfeeding, and infant/child feeding. WIC also provides nutritious foods for women and caregivers to give their infants/children, as well as referrals to support participants’ needs. WIC staff can assist participants by:

• Providing individualized nutrition education in an easy-to-understand format that is appropriate for the learning level of the participant/caregiver. Most education materials should be written for a 5th to 7th grade reading level. Be sensitive to the unique learning needs and style of the participant/caregiver, which may mean using food models, posters, and handouts(12).

• Providing referrals to promote parenting and infant/child feeding skills, including referrals to local home visiting programs, parenting programs, and early intervention services.

• Providing referrals to those with substance misuse for professional treatment, referring to community resources for alcohol and substance use support groups, and providing breastfeeding promotion and support to women enrolled in supervised medication-assisted treatment programs.

• Encouraging participants/caregivers with mental illnesses, intellectual disabilities, and physical disabilities to follow health care provider’s plan of care. Coordinate with health care providers as needed.

• Providing individualized food packages, tailored to meet the needs of participants. Some caregivers who have a limited ability to make appropriate feeding decisions/prepare food may be unable to prepare powder or concentrated infant formula. Thus, for the safety of the infant, State WIC Agencies may allow ready-to-feed (RTF) WIC formulas to be issued when it is determined that the caregiver may have difficulty correctly diluting powder or concentrated formulas. Please refer to your State WIC Agency’s specific policies regarding the issuance of RTF, as policies vary from state to state.

1. Perez-Escamilla R, Segura-Perez S, Lott M, on behalf of the RWJF HER Expert Panel on Best Practices for Promoting Healthy Nutrition, Feeding Patterns, and Weight Status for Infants and Toddlers from Birth to 24 Months. Feeding guidelines for infants and young toddlers: a responsive parenting approach. Durham, NC: Healthy Eating Research, 2017. [cited 2017 Jul 24]. Available from: http://healthyeatingresearch.org/.

2. Smith VC, Wilson CR, Committee on Substance Use and Prevention. Families affected by parental substance use. Pediatrics. 2016;138:e1-e13.

3. Hatzis D, Dawe S, Harnett P, Barlow J. Quality of caregiving in mothers with illicit substance use: a systematic review and meta-analysis. Substance Abuse: Research and Treatment.2017;11:1-15.

4. Child Welfare Information Gateway. Parental substance use and the child welfare system. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau. 2014 [cited 2017 Jul 7]. Available from: https://www.childwelfare.gov/pubPDFs/parentalsubabuse.pdf.

5. Substance Abuse and Mental Health Services Administration. Supporting infants, toddlers, and families impacted by caregiver mental health problems, substance abuse, and trauma, a community action guide. DHHS Publication No. SMA-12-4726. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012. [cited 2017 Jul 7]. Available from: https://store.samhsa.gov/shin/content/SMA12-4726/SMA12-4726.pdf.

6. Krmpotich T, Mikulich-Gilbertson S, Sakai J, Laetitia T, Banich MT, Tanabe J. Impaired decision-making, higher impulsivity, and drug severity in substance dependence and pathological gambling. Journal of Addiction Medicine. 2015;9(4):273-280.

7. Verdejo-Garcia A, Perez-Garcia M, Bechara A. Emotion, decision-making and substance dependence: a somatic-marker model of addiction. Current Neuropharmacology. 2006;4(1):17-31.

8. Mayo Clinic [Internet]. Minneapolis: Patient Care and Health Information; [Oct 2015: cited 2018 May 4] Mental Illness. Available from: https://www.mayoclinic.org/diseases-conditions/mental-illness/symptoms-causes/syc-20374968.

9. Tabak I, Zablocka-Zytka L, Ryan P, Poma SZ, Joronen K, Vigano G, Simpson W, Paavilainen E, Scherbaum N, Smith M, Dawson I. Needs, expectations and consequences for children growing up in a family where the parent has a mental illness. International Journal of Mental Health Nursing. 2016;25:319-329.

10. Dennis C, McQueen K. The relationship between infant-feeding outcomes and postpartum depression: a qualitative systematic review. Pediatrics. 2009;123:e736-e751.

11. Kilbourne AM, Rofey DL, McCarthy JF, Post EP, Welsh D, Blow FC. Nutrition and exercise behavior among patients with bipolar disorder. Bipolar Disorders. 2007;9:443-452.

12. Kwan CL, Gelberg HAL, Rosen JA, Chamberlin V, Shah C, Nguyen C, Pierre JM, Erickson ZD, Mena SJ, King M, Arnold I, Baker MR, Meyer HB, Ames D. Nutrition counseling for adults with severe mental illness: key lessons learned. Journal of the Academy of Nutrition and Dietetics. 2013;114(3):369- 374.

13. American Association on Intellectual and Developmental Disability. Washington DC: Intellectual Disability; [Jan 2018: cited 2018 May 4]. Available from: http://aaidd.org/intellectual-disability/definition#.WuxfKXkUmPx.

14. Granzvist P, Forslund T, Fransson M, Springer L, Lindberg. Mothers with intellectual disability, their experiences of maltreatment, and their children’s attachment representations: a small-group matched comparison study. Attachment and Human Development. 2014;16:417-436.

15. Wilson S, McKenzie K, Quayle E, Murray G. A systematic review of interventions to promote social support and parenting skills in parents with an intellectual disability. Child: Care, Health and Development. 2013;40:7-19.

16. Gameren-Oosterom HBMV, Fekkes M, Reijneveld SA, Oudesluys-Murphy AM, Verkerk PH, Wouwe JPV, Buitendijk SE. Practical and social skills of 16-19-year-olds with Down syndrome: independence still far away. Research in Developmental Disabilities. 2013;34:4599-4607.

17. Koritsas S, Iacono T. Weight, nutrition, food choice, and physical activity in adults with intellectual disability. Journal of Intellectual Disability Research. 2015;60(4):355-364.

18. Centers for Disease Control and Prevention. About teen pregnancy. [cited 2017 Aug 2]. Available from: https://www.cdc.gov/teenpregnancy/about/index.htm.

19. Chico E. Gonzalez A, Ali N, Steiner M, Fleming AS. Executive function and mothering: challenges faced by teenage mothers. Developmental Psychobiology. 2014;56:1027-1035.

20. Youth.gov. Pregnancy Prevention – Adverse Effects. [cited 2017 Aug 2]. Available from: http://youth.gov/youth-topics/teen-pregnancy-prevention/adverse-effects-teen-pregnancy.

21. McPeak KE, Sandrock D, Spector ND, Pattishal AE. Important determinants of newborn health: postpartum depression, teen parenting, and breastfeeding. Current Opinion in Pediatrics. 2015;27:138-144.

Self-reporting of a diagnosis by a medical professional should not be confused with self-diagnosis, where a person simply claims to have or to have had a medical condition without any reference to professional diagnosis. A self-reported medical diagnosis (“My doctor says that I have/my son or daughter has…”) should prompt the CPA to validate the presence of the condition by asking more pointed questions related to that diagnosis.