Shortcommunication
Earlyintroductionofcomplementary foodsamonginfantsexposedtomaternal incarceration inutero
NutritionandHealth 1–6
©TheAuthor(s)2026
Articlereuseguidelines: sagepub.com/journals-permissions
DOI:10.1177/02601060251414561 journals.sagepub.com/home/nah
ElissaDakers1 ,JenniferCoates2,JoannaBoyles3 ,NatalieSlopen1 andBethanyKotlar1
Abstract
Background: Earlynutritioniscriticaltolaterhealthoutcomes.Infantsexposedtomaternalincarcerationareamarginalizedpopulationandmaybeatelevatedriskforsuboptimalfeeding.
Aim: Toassessadherencetorecommendedtimingofcomplementaryfoodintroductionamonginfantsexposedto maternalincarceration inutero.
Methods: Weanalyzeddatafrom69infantsandcaregiversinGeorgia.Formerlyincarceratedmothers(n = 17)andnonmaternalcaregivers(n = 52)reportedtimingofcomplementaryfoodintroduction.Regressionanalysesassessedassociationswithindependentvariables,includingpoverty,foodinsecurity,SupplementalNutritionAssistanceProgramreceipt, andcaregivereducation,psychologicaldistress,andage.
Results: Approximately47.8%ofinfantsreceivedcomplementaryfoodsearly,definedasbeforefourmonthsofage.The meanageofintroductionwas3.6months.Caregiverdistresswasassociatedwithearlierintroduction.
Conclusion: Thispopulationofcaregiversrequirestailorednutritioneducation, financialassistance,andmentalhealth andsocialsupportservicestopromoteoptimalinfantfeedingpractices.
Keywords
Maternalincarceration,caregivers,complementaryfeeding,childwelfare,equity
Introduction
Infancyisasensitiveperiodduringwhichexposurescan havelifelonghealthimplications,withearlynutritionplayingavitalroleinphysicalandcognitivedevelopment (Mooreetal.,2017).TheAmericanAcademyof Pediatrics(AAP)providesevidence-basedguidelineson infantfeeding,includingrecommendationsonthetiming ofcomplementaryfoodintroduction.Theseguidelines adviseexclusivebreastfeedingorformulafeedinguntil sixmonthsofage,withcomplementaryfoodsintroduced noearlierthanfourmonths(AAP,2023).Earlyintroduction ofcomplementaryfoodsislinkedtoadversechildhealth outcomes,includingobesityandnutrientdeficiencies, whichincreaselifelongriskofnoncommunicablediseases andimpairedcognitiveskills(Adair,2014;Williams, 2006;YoungandKrebs,2014).
Between2016and2022,approximately10.7%ofrespondentstotheUnitedStates(U.S.)NationalSurveyof Children’sHealth(NSCH)introducedcomplementaryfoods early(Dingetal.,2024).Theprevalenceofearlyintroduction variesacrosssociodemographicgroups:accordingtoNSCH datafrom2016to2018,earlyintroductionwasmorecommon
amonginfantsinhouseholdsbelowthefederalpovertyline (19.8%)andthosewhosemothershadahighschooldiploma orless(18.4%);earlyintroductionwasalsomorecommon amonginfantsbelongingtohistoricallymarginalizedracial groups(14.4–25.2%)comparedtowhiterespondents (13.8%)(Chiangetal.,2023).A2022studyonparental decision-makingsurroundingtheintroductionofcomplementaryfoodsidentifiedcaregivermentalhealth,age,andenrollmentinsocialservicesasadditionalfactorsinfluencingearly introduction(Thompsonetal.,2023).
Acriticallyunderstudiedpopulationinthiscontextis infantsexposedtomaternalincarceration.TheU.S.has
1DepartmentofSocialandBehavioralSciences,HarvardT.H.ChanSchool ofPublicHealth,Boston,MA,USA
2FriedmanSchoolofNutritionScienceandPolicy,TuftsUniversity, Boston,MA,USA
3MotherhoodBeyondBars,Atlanta,GA,USA
Correspondingauthor:
ElissaDakers,DepartmentofSocialandBehavioralSciences,HarvardT.H. ChanSchoolofPublicHealth,677HuntingtonAve,Boston,MA,USA. Email:edakers@hsph.harvard.edu
thehighestrateofwomen’sincarcerationglobally,with massincarcerationsystematicallytargetingpoorand raciallymarginalizedcommunities(Alexander,2012; PettitandWestern,2004;Roberts,1997).Anestimated 2–4%ofthoseadmittedtostateprisonsarepregnant,and mostpeoplewhogivebirthwhileincarceratedareseparated fromtheirnewborns(Maruschak,2025;Sufrinetal.,2020). Thisseparationrequiresnonmaternalcaregiverstoassume infantcareresponsibilities,oftenleadingtocaregiving instabilityandcurtailinginfants’ abilitytoreceivebreast milk(Kotlaretal.,2025a).
Infantsexposedtomaternalincarceration inutero represent avulnerablesubsetofchildren,facingbothprenatalandpostnatalexposures.Incarcerationduringpregnancycanleadto maternalstress,disruptedaccesstoprenatalcare,andseparation atbirth(Kotlaretal.,2025a).Compoundingthis,following birth,caregiversfortheseinfants includingbothnonmaternal caregiversandreleasedmothers facedistinctchallenges. Nonmaternalcaregiversoftenexperiencesubstantial financial andemotionalstresswhenassumingresponsibilityfornewborns(Kotlaretal.,2024,2025b;Pendletonetal.,2021). Formerlyincarceratedmothersoftenadditionallyexperience economichardship,stigma,andinstability(Ardittietal., 2003).Thesecircumstancesmaycreatecaregivingenvironmentsthatadverselyaffectadherencetoinfantfeeding guidelines.
Existingresearchonchildnutritioninthecontextofparentalincarcerationhasprimarilyexaminedbreastfeedingor nutritionamongolderchildren(Asioduetal.,2021;Jackson andVaughn,2017).Therehasbeenlimitedattentionto otheraspectsofearlynutrition,particularlyamonginfants exposedtomaternalincarceration inutero.Thisstudy aimstoaddressthatgapbyexamininginfantfeedingpracticeswithinthisvulnerablepopulation,withafocusontimingofcomplementaryfoodintroduction.Wehypothesized thatadherencetoinfantfeedingguidelineswouldbelower thaninthegeneralpopulationandthateconomicandpsychosocialfactorsamongcaregivers includingpoverty, foodinsecurity,nonreceiptofSupplementalNutrition AssistanceProgram(SNAP)benefits,lowerlevelsofeducation,psychologicaldistress,andolderage wouldbe associatedwithagreaterriskofnonadherence.Giventhe linksbetweenearlynutritionandhealthoutcomes,identifyingdisparitiesinfeedingpracticesamongthispopulationis criticaltoinformingpoliciesandinterventionsthatpromote optimalnutrition.
Methods
Wedrewdataforthisstudyfromsurveyquestionsinthe BirthBeyondBars(BBB)Study,anongoingprospective birthcohortofchildrenexposedprenatallytotheirmothers’ incarceration.Mothersornonmaternalcaregiversofachild whoexperiencedmaternalincarcerationinprisonorjailat anypointduringtheirgestationareeligibleforenrollment.
Intakesurveysareconductedatenrollment,followedby follow-upsurveysat3,6,9,and12months.Datacollection wasapprovedbyHarvard’sLongwoodMedicalArea InstitutionalReviewBoard(IRB20-1215,21-1247). Additionaldetailsonstudydesignanddatacollectionare providedinSupplementA.
Forthisanalysis,weusedresponsesfromintakeand follow-upsurveysconductedwithprimarycaregiversin GeorgiabetweenAugust2020andMarch2025.Basedon analyticinclusioncriteria,participantswereexcludedif feedingdatawereinsufficienttoassesstheprimaryoutcome ofinterest(i.e.,adherencetoAAPguidelinesonthetiming ofcomplementaryfoodintroduction).Reasonsforinsufficientdataincludedmissingsurveyresponses,lossto follow-up,ortheinfantnotyetreachingtheagerequired forassessment.Thisresultedintheexclusionof18infants. Infantswhospentmorethan30daysintheneonatalintensivecareunitwerealsoexcluded,asfeedingduringthisperiodwasprimarilymanagedbymedicalstaff,ratherthan caregivers.Thisresultedintheexclusionoftwoinfants. Oneadditionalinfantwasexcludedbecausetheyrequired afeedingtubeduetoahealthcondition,precludingtheoutcomeassessment.Intotal,69participantscontributeddata.
Weassessedtheoutcomeusingclosed-ended, feeding-relatedsurveyresponses.Duringfollow-upsurveys,caregiverswereaskedwhethertheinfanthadever receivedbabycereal,pureedfoods,solids,orwater(“complementaryfoods”).Iftheyanswered “yes,” theywere askedtoreportthedateof firstintroduction.Wethencalculatedtheageatintroductionusingthechild’sdateofbirth. Infantswereclassifiedas “adherent” ifcomplementary foodshadnotbeenintroducedbeforefourmonthsofage, and “non-adherent” ifintroducedearlier.
Independentvariablesincludedbothstaticandtimevaryingmeasures.Staticvariables,includingcaregiver ageandeducation,wererecordedatenrollment. Time-varyingvariableswereassessedatenrollmentand three-monthsurveys,includingpoverty,foodinsecurity, receiptofSNAPbenefits,andcaregiverpsychologicaldistress(measuredusingtheKessler-6scale).Participants wereclassifiedas “exposed” iftheymetthecriteriaateither timepoint.Ofnote,allparticipantsinthesampleare enrolledintheWomen,Infants,andChildren(WIC) NutritionProgram;therefore,SNAPistheonlysocialprogramexamined.Potentialconfounderswereidentified usingdirectedacyclicgraphs(DAGs),includingcaregiver employmentstatus,presenceofotherchildreninthehousehold,andadversebirthoutcomes.AdetailedlistofmeasuresisprovidedinSupplementB,andDAGsare providedinSupplementC.Forregressionanalyses,listwise deletionwasappliedsothatrecordswithmissingdatawere omittedfromthegivenmodel.
Weusedmultivariablelogisticregressiontoassessassociationsbetweenindependentvariablesandadherenceto feedingguidelines,andlinearregressiontoevaluate
Table1. Participantcharacteristics.
CharacteristicCategory n %
HouseholdCharacteristics
Poverty(n = 69)Abovefederalpovertyline3855.1% Belowfederalpovertyline3144.9%
Foodinsecurity(n = 52)Notfoodinsecure3771.2% Foodinsecure1528.8%
SNAPparticipation(n = 65)DoesnotreceiveSNAP2843.1% ReceivesSNAP3756.9%
Otherchildreninthehousehold(n = 49)Nootherchildren816.3% ≥1otherchild4183.7%
CaregiverCharacteristics
Age(n = 69)Ageinyears69Mean:43.5
Range:23–71
Motherornonmaternalcaregiver(n = 69)Mother1724.6% Nonmaternalcaregiver5275.4% Race(n = 69)White3753.6% Blackormixedrace3246.4%
Education(n = 67)Completedhighereducation1116.4% Nohighereducation5683.6%
Employmentstatus(n = 65)Employed2741.5% Unemployed3858.5%
Distress(n = 68)Kesslerscore<5(nodistress)5783.8% Kesslerscore ≥5(distress)1116.2%
Infantcharacteristics
Adversebirthoutcomes(n = 69)Noadversebirthoutcomes4971.0% Adversebirthoutcome2029.0%
Breastfeeding(n = 69)Neverbreastfed5985.5% Initiatedbreastfeeding1014.5% Stillbreastfeedingatintake45.8%
associationswiththeageofcomplementaryfoodintroduction.AllanalyseswereconductedinRStudio(version 2025.09.1 + 401).
Results
Thestudysamplereflectedahighlymarginalizedpopulation withsignificantsocioeconomicvulnerabilities:44.9% reportedincomesbelowthefederalpovertyline,56.9% reportedreceivingorapplyingforSNAPbenefits,and 28.8%reportedfoodinsecurity.Mostcaregiverswerenonmaternal(75.4%),and83.6%hadobtainedahighschooldiplomaorless.Nearlyhalfofcaregivers(46.4%)identifiedas Blackormixedrace.AcompletelistofparticipantcharacteristicsisincludedinTable1.Notably,inmostcases,mothers wereofferedtheopportunityto initiatebreastfeedingimmediatelypostpartum;however,only10(14.5%)didso.Onlysix (8.7%)infantswereborntomothersreleasedbeforetheirbirth andabletocontinue;however,atthetimeofstudyenrollment, justfour(5.8%)werestillbreastfeeding.
Overall,47.8%ofinfantsreceivedcomplementaryfoods beforefourmonthsofage,withhigherratesofearlyintroductionamongthosewithcaregiversreportingpsychologicaldistress(72.7%),releasedmothers(64.7%),white caregivers(59.5%),caregiverswhodidnotreceiveSNAP
(57.1%),caregiverswhodidnotreportfoodinsecurity (56.8%),andcaregiverswithahighschooleducationor less(53.6%).Themeanageofintroductionwas3.6months andrangedfrom2.6to4.1monthsacrosssubgroups.In Table2,wepresentmeanagesofintroductionandpercentagesofinfantswhoreceivedcomplementaryfoodsbefore fourmonthsbythecovariatesofinterest.
Inlinearregressionmodels,caregiverpsychologicaldistresswassignificantlyassociatedwithearlierintroduction ofcomplementaryfoods(unadjusted: 1.16months;95% CI: 2.28, 0.03;adjustedmodel: 1.60months;95% CI: 2.86, 0.34).Noothervariableswereassociated withearlierintroductionat p <0.05.
Inlogisticregressionmodels,noindependentvariables wereassociatedwithadherencetofeedingguidelinesat p <0.05,althoughsomeapproachedsignificance( p <0.1). Inparticular,caregiverpsychologicaldistresswasassociatedwithloweroddsofadherenceinbothunadjusted (OR = 0.36;95%CI:0.07,1.39)andadjustedmodels (OR = 0.22;95%CI:0.03,1.07)(seeTable3).
Discussion
Our findingssuggestthatinfantsexposedtomaternalincarceration inutero mayfaceagreaterriskofsuboptimalnutrition.
Table2. Results:descriptive findingsforintroductionofcomplementaryfoods.
Meanageofintroductionb %Earlyintroductionc
Overall(n = 69)a 3.647.8%
PovertyAbovefederalpovertyline(n = 38)3.852.6%
Belowfederalpovertyline(n = 31)3.351.6%
FoodinsecurityNotfoodinsecure(n = 37)3.556.8%
Foodinsecure(n = 15)3.833.3%
SNAPparticipationDoesnotreceiveSNAP(n = 28)3.657.1%
ReceivesSNAP(n = 37)3.451.4%
DistressDidnotreportdistress(n = 57)3.749.1% Reporteddistress(n = 11)2.672.7%
CaregiverMother(n = 17)3.064.7%
Nonmaternalcaregiver(n = 52)3.748.1%
RaceWhite(n = 37)3.559.5% Blackormixedrace(n = 32)3.643.8%
aThetotalsamplesizewas69;however,completedatawerenotavailableforallcovariateslistedinthistable.
bThemeanage(inmonths)atwhichinfantsinthesample firstreceivedcomplementaryfoods(i.e.,babycereal,pureedfoods,solidfoods,orwater).
cThepercentageofinfantsinthesamplewhoreceivedcomplementaryfoodsearly(i.e.,beforefourmonthsofage).
Table3. Results:logisticandlinearregression.1
UnadjustedAdjusted5
Adherenceto guideline3
Meandifferenceinageof introduction(months)
Adherenceto guideline3 Meandifferenceinageof introduction(months)
Independentvariable2 OR(95%CI)Beta(95%CI)OR(95%CI)Beta(95%CI)
Householdpovertya
Householdfoodinsecurityb 2.62(0.77,9.88)0.30( 0.71,1.31)4.57(0.97,26.69)0.70( 0.49,1.90)
HouseholdSNAPbenefitsc 1.26(0.47,3.43) –0.28( 1.11,0.56)1.23(0.41,3.67) 0.17( 1.10,0.77)
Higherlevelofcaregiver educationd 1.38(0.37,5.31)0.63( 0.53,1.79)1.42(0.38,5.52)0.63( 0.55,1.81)
Caregiverdistresse 0.36(0.07,1.39) 1.16( 2.28, 0.03)4 0.22(0.03,1.07) 1.60( 2.86, 0.34)4
Caregiveragef 1.04(0.996,1.08)N/A1.04(0.992,1.09)N/A
1Eachrowrepresentsaseparatemodelassessingtheassociationbetweentheindependentvariableandtheoutcomeofinterest(i.e.,earlyintroductionof complementaryfoods).
2Samplesizeforeachmodelfollowinglistwisedeletion: a n = 69; b n = 52; c n = 65; d n = 67; e n = 68; f n = 69.
3“Adherence” isdefinedasdelayingtheintroductionofcomplementaryfoodsuntiltheinfantisatleastfourmonthsofage.
4Statisticallysignificant.
5Modelsadjustedfor: aotherchildreninhousehold; botherchildreninhousehold; chouseholdpoverty; dcaregiveremploymentstatus; eadversebirth outcomesandotherchildreninhousehold; fcaregiveremploymentstatus.
Nearlyhalf(47.8%)ofinfantsinoursamplereceivedcomplementaryfoodsbeforefourmonthsofage aratesignificantlyhigherthanthegeneralpopulation(10.7%)(Ding etal.,2024)andothermarginalizedgroups(14.4–25.2%); themeanageofcomplementaryfoodintroductionforour sample(3.6months)wasalsoearlierthanthegeneralpopulationestimateof5.7months(Chiangetal.,2023).These patternsmayreflecttheimpactofstructuralbarriersto breastfeedingwithinthecontextofmaternalincarceration, asformula-fedinfantsaremorelikelytoreceivecomplementaryfoodsearly(AAP,2023).
Caregiverpsychologicaldistresswasassociatedwith earlierintroductionofcomplementaryfoods.This finding
alignswithevidencelinkingcaregivermentalhealthto infantfeedingpractices(Thompsonetal.,2023)andmay reflectthesubstantialemotionaland financialburdens maternalincarcerationimposesoncaregivers.Accessto mentalhealthservicesandsocialsupportprogramsiscriticalforpromotingcaregiverwell-beingand,inturn,optimal infantfeedingpractices.
Whileregressionresultsdidnotachievesignificance, contrarytoourhypothesis,arelativelylowproportionof infantsinhouseholdsreportingfoodinsecurityreceived complementaryfoodsbeforefourmonths(33.3%)comparedtothosenotreportingfoodinsecurity(56.8%).This trendwarrantsfurtherinvestigationandmayreflectthe
effectsofprotectivepolicies.InGeorgia,WIC usedbyall householdsintheBBBStudy doesnotcovercomplementaryfoodsbeforesixmonths.Thus,relianceonWICmay delaysolidfoodintroductioninfood-insecurehouseholds. However,thisstudydoesnotassessbarrierstoaccessing formula,sowecannotruleoutthepossibilitythatsome caregiversmayhavedilutedformulatorationsupply,displacingnutrients.Thisinsightunderscorestheneedto pairadequate financialassistancewitheducationoninfant feedingtoensurebothtimelyandappropriateinfant nutrition.
Thisstudyhasseverallimitations.Oursmallsamplesize reducedstatisticalpowertodetectassociations,resultingin someoddsratioswithwideconfidenceintervalsthatlimit precisionandinterpretability.Twologisticmodels(i.e., assessingfoodinsecurityandcaregiverpsychologicaldistress)hadevents-per-variableratiosbelowtherecommendedthreshold,increasingtheriskofoverfittingand spuriousassociations(SupplementD).Therefore,these analysesshouldbeconsideredexploratoryandinterpreted cautiously.Feedingdatawerebasedoncaregiverreports, whichmaybesubjecttorecallorreportingbias;however, caregiverrecalliswidelyacceptedforassessinginfant andyoungchildfeedingpracticesanddietaryintakes. Thestudyreliedonavolunteersample,whichmayintroduceparticipationbiasandlimitgeneralizability. Caregiversincludedbothmothersandnonmaternalcaregivers,aswellasbothjailandprisonincarceration,introducingheterogeneityinexperience;however,thisapproach wasnecessarygiventhesmall,underrepresentedpopulation.Last,severalpotentialconfounders,includingmaternalsubstanceuse,lengthofincarceration,andcaregiver supportnetworks,wereunavailableandcouldinfluence observedassociations.
These findingshighlighttheneedfortailoredpolicies andprogramstosupportoptimalfeedingpracticesamong infantsexposedtomaternalincarceration.Caregiversin thesecontextsfaceintersectingchallengesthatmayunderminehealthyfeeding.Expandingaccesstonutritioneducation, financialsupportforformulaandnutritionally appropriatecomplementaryfoods,andintegratedsocial andmentalhealthservicesisessentialtoaddressingthese disparities.Futureresearchshouldassesstheeffectiveness ofexistingsafetynetprograms,identifyadditionalbarriers tooptimalinfantnutrition,andexploreotheraspectsof complementaryfeeding,includingmealfrequencyanddietarydiversity.
Acknowledgements
Theauthorswouldliketoacknowledgethecontributionsofstaff andleadershipatMotherhoodBeyondBars.
ORCIDiDs
ElissaDakers https://orcid.org/0009-0006-9536-5505
JoannaBoyles https://orcid.org/0009-0009-0503-5871
Ethicalconsiderations
ThisstudywasapprovedbyHarvard’sLongwoodMedicalArea InstitutionalReviewBoardunderIRB21-1247,approvedin January2022andIRB20-1215,approvedinJuly2020.
Consenttoparticipate
Theprivacyrightsofallparticipantshavebeenobserved. Informedconsentwascompletedwithallparticipantsonenrollmentintothestudy.
Authorcontributions
BKwasprimarilyresponsibleforthestudyconceptionanddesign, withJCinasupportingrole.Materialpreparationandanalysis wereperformedbyED.JB,NS,andJCcontributedtoandedited themanuscript.The firstdraftofthearticlewaswrittenbyED.
Funding
Theauthorsdisclosedreceiptofthefollowing financialsupportfor theresearch,authorship,and/orpublicationofthisarticle:This workwassupportedbytheEuniceKennedyShriverNational InstituteofChildHealthandHumanDevelopment(F32 HD117535),MaternalandChildHealthBureau(T03MC0764812-06),andNationalHeart,Lung,andBloodInstitute(T32 HL098048).
Declarationofconflictinginterests
Theauthorsdeclaredthefollowingpotentialconflictsofinterest withrespecttotheresearch,authorship,and/orpublicationof thisarticle:BethanyKotlarservedasaboardmemberof MotherhoodBeyondBarsinanunpaidcapacitybetween2020 and2023.JoannaBoylesservesasapaidstaffmemberof MotherhoodBeyondBars.
Dataavailability
Thedatathathavebeenusedareconfidential.
Supplementalmaterial
Supplementalmaterialforthisarticleisavailableonline.
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