Count Every Bite to Make "Every Bite Count": Measurement Gaps and Future Directions for Assessing Diet From Birth to 24 Months.

Overweight and obesity are pressing public health problems, and development of these conditions is linked to the earliest life stages.1US Departments of Agriculture and Health and Human ServicesDietary Guidelines for Americans, 2020-2025: Make every bite count with the dietary guidelines.https://www.dietaryguidelines.gov/sites/default/files/2021-03/Dietary_Guidelines_for_Americans-2020-2025.pdfDate accessed: June 9, 2022Google Scholar These early life stages include infancy (0 through 11 months) and toddlerhood (12 through 23 months),1US Departments of Agriculture and Health and Human ServicesDietary Guidelines for Americans, 2020-2025: Make every bite count with the dietary guidelines.https://www.dietaryguidelines.gov/sites/default/files/2021-03/Dietary_Guidelines_for_Americans-2020-2025.pdfDate accessed: June 9, 2022Google Scholar collectively referred to as birth to 24 months (B-24). Systematic reviews from the Pregnancy and Birth to 24 Months Project found that risk of childhood obesity is associated with the types of foods introduced during the complementary feeding period,2English L.K. Obbagy J.E. Wong Y.P. et al.Types and amounts of complementary foods and beverages consumed and growth, size, and body composition: A systematic review.Am J Clin Nutr. 2019; 109: 956S-977Shttps://doi.org/10.1093/AJCN/NQY281Abstract Full Text Full Text PDF PubMed Google Scholar,3English L.K. Obbagy J.E. Wong Y.P. et al.Timing of introduction of complementary foods and beverages and growth, size, and body composition: A systematic review.Am J Clin Nutr. 2019; 109: 935S-955Shttps://doi.org/10.1093/AJCN/NQY267Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar which begins at about age 6 months when complementary foods and beverages are first introduced and continues to age 24 months as children transition to family foods.4Dietary Guidelines Advisory Committee2020. Scientific Report of the 2020 Dietary Guidelines Advisory Committee: Advisory Report to the Secretary of Agriculture and the Secretary of Health and Human Services. U.S. Department of Agriculture, Agricultural Research Service, Washington, DC.https://doi.org/10.52570/DGAC2020Google Scholar There is mounting evidence that the dietary patterns established during complementary feeding are not only associated with current and future weight status2English L.K. Obbagy J.E. Wong Y.P. et al.Types and amounts of complementary foods and beverages consumed and growth, size, and body composition: A systematic review.Am J Clin Nutr. 2019; 109: 956S-977Shttps://doi.org/10.1093/AJCN/NQY281Abstract Full Text Full Text PDF PubMed Google Scholar,3English L.K. Obbagy J.E. Wong Y.P. et al.Timing of introduction of complementary foods and beverages and growth, size, and body composition: A systematic review.Am J Clin Nutr. 2019; 109: 935S-955Shttps://doi.org/10.1093/AJCN/NQY267Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar,5Rose C.M. Birch L.L. Savage J.S. Dietary patterns in infancy are associated with child diet and weight outcomes at 6 years.Int J Obes (Lond). 2017; 41: 783-788https://doi.org/10.1038/IJO.2017.27Crossref PubMed Scopus (0) Google Scholar and health outcomes6Golley R.K. Smithers L.G. Mittinty M.N. Emmett P. Northstone K. Lynch J.W. Diet quality of U.K. infants is associated with dietary, adiposity, cardiovascular, and cognitive outcomes measured at 7-8 years of age.J Nutr. 2013; 143: 1611-1617https://doi.org/10.3945/JN.112.170605Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar but also associated with diet quality in later life stages. For example, intake of fruits, vegetables, and sugar-sweetened beverages during infancy are associated with fruit and vegetable7Grimm K.A. Kim S.A. Yaroch A.L. Scanlon K.S. Fruit and vegetable intake during infancy and early childhood.Pediatrics. 2014; 134: S63-S69https://doi.org/10.1542/PEDS.2014-0646KCrossref PubMed Scopus (0) Google Scholar and sugar-sweetened beverage8Park S. Pan L. Sherry B. Li R. The association of sugar-sweetened beverage intake during infancy with sugar-sweetened beverage intake at 6 years of age.Pediatrics. 2014; 134: S56-S62https://doi.org/10.1542/peds.2014-0646JCrossref PubMed Scopus (107) Google Scholar intakes at age 6 years. In fact, risk for childhood obesity may begin even before solid foods are introduced, as breastfeeding is also associated with higher diet quality and reduced risk of obesity in childhood.9Perrine C.G. Galuska D.A. Thompson F.E. Scanlon K.S. Breastfeeding duration is associated with child diet at 6 years.Pediatrics. 2014; 134: S50https://doi.org/10.1542/PEDS.2014-0646ICrossref PubMed Scopus (0) Google Scholar, 10Dewey K.G. Güngör D. Donovan S.M. et al.Breastfeeding and risk of overweight in childhood and beyond: A systematic review with emphasis on sibling-pair and intervention studies.Am J Clin Nutr. 2021; 114: 1774-1790https://doi.org/10.1093/AJCN/NQAB206Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 11Thompson H.R. Borger C. Paolicelli C. Whaley S.E. Reat A. Ritchie L. The relationship between breastfeeding and initial vegetable introduction with vegetable consumption in a national cohort of children ages 1–5 years from low-income households.Nutrients. 2022; 14: 1740https://doi.org/10.3390/NU14091740/S1Crossref PubMed Google Scholar In recognition that infant and toddler nutrition can influence diet quality and health outcomes throughout the life span, the 2020-2025 Dietary Guidelines for Americans (DGA) for the first time included comprehensive dietary recommendations for B-24, and established dietary patterns for the second year of life.1US Departments of Agriculture and Health and Human ServicesDietary Guidelines for Americans, 2020-2025: Make every bite count with the dietary guidelines.https://www.dietaryguidelines.gov/sites/default/files/2021-03/Dietary_Guidelines_for_Americans-2020-2025.pdfDate accessed: June 9, 2022Google Scholar This latest edition of the DGA emphasizes that “every bite counts” at every life stage. In contrast to the popular but not evidence-based rhyme “food before 1 is just for fun,”12Belz K. Parents face a bewildering range of food advice. These tips can help.The Washington Post. April 10, 2022; Google Scholar this new and evidence-based mantra that “every bite counts” highlights the importance of every bite, especially as feeding and eating behaviors are introduced and learned during early life stages. Since every bite counts, the field of infant and toddler nutrition now faces a challenge: How do we count (measure) every bite? Given the need to measure the new DGA recommendations for infants and toddlers, a new dietary assessment work group, described herein, was formed. The purpose of this commentary by the National Collaborative for Childhood Obesity Research (NCCOR) colleagues is to propose a process for identifying measurement gaps and to provide research recommendations for closing those gaps. The evaluation of interventions, nutrition education tools, dietetics practices, and policy changes that are designed to improve B-24 dietary patterns is contingent on precise collection and analysis of dietary data. Measurement has been a focus of NCCOR for over a decade, exemplifed by tools like the NCCOR Measures Registry and Measures Registry Learning Suite.13National Collaborative on Childhood Obesity ResearchMeasures Registry.https://www.nccor.org/nccor-tools/measures/Date accessed: June 10, 2022Google Scholar,14McKinnon R.A. Reedy J. Berrigan D. Krebs-Smith S.M. The National Collaborative on Childhood Obesity Research catalogue of surveillance systems and measures registry: New tools to spur innovation and increase productivity in childhood obesity research.Am J Prev Med. 2012; 42: 433-435https://doi.org/10.1016/J.AMEPRE.2012.01.004Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar NCCOR brings together the 4 leading funders of childhood obesity research: the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), the Robert Wood Johnson Foundation, and the US Department of Agriculture (USDA). With participation from each of these 4 leaders, NCCOR represents a partnership that continually assesses the needs in childhood obesity research, develops joint projects to address gaps and make strategic advancements, and works together to generate synergetic ideas to reduce childhood obesity.15National Collaborative on Childhood Obesity Research.https://www.nccor.org/Date accessed: June 10, 2022Google Scholar In response to the 2020-2025 DGA and the 2020-2030 Strategic Plan for NIH Nutrition Research,1US Departments of Agriculture and Health and Human ServicesDietary Guidelines for Americans, 2020-2025: Make every bite count with the dietary guidelines.https://www.dietaryguidelines.gov/sites/default/files/2021-03/Dietary_Guidelines_for_Americans-2020-2025.pdfDate accessed: June 9, 2022Google Scholar,16National Institutes of Health Nutrition Research Task Force2020–2030 Strategic Plan for NIH Nutrition Research.https://dpcpsi.nih.gov/onr/strategic-planDate accessed: June 6, 2022Google Scholar a new NCCOR B-24 Diet Assessment Work Group was formed in March 2021 and met biweekly for 1 year to identify existing measurement tools and methods, as well as potential gaps in these areas. The work group comprises 13 members from multiple agencies, including the USDA Food and Nutrition Service (Center for Nutrition Policy and Promotion and Office of Policy Support), the CDC (Division of Nutrition, Physical Activity, and Obesity), and the NIH (National Cancer Institute; Eunice Kennedy Shriver National Institute of Child Health and Human Development), and was facilitated by FHI 360. The work group’s long-term goal is to identify research gaps to spur innovative research for the development of new measurement tools and methods that can be used to generate data to inform future iterations of the B-24 dietary guidelines. This work is intended to complement existing federal funding initiatives focused on nutrition in young children less than 5 years of age.17NOT-CA-21-108: Notice of Special Interest (NOSI): Dietary, physical activity, sedentary behavior and sleep assessment methodologies among infants and young children (birth to 5 years) through adults.https://grants.nih.gov/grants/guide/notice-files/NOT-CA-21-108.htmlDate accessed: June 10, 2022Google Scholar,18Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)Human milk as a biological system (R01 Clinical Trial Optional).https://grants.nih.gov/grants/guide/rfa-files/RFA-HD-22-020.htmlDate accessed: June 9, 2022Google Scholar To identify the most effective ways to inform future B-24 dietary guidelines, the work group reviewed the future directions section in the Scientific Report of the 2020 Dietary Guidelines Advisory Committee.4Dietary Guidelines Advisory Committee2020. Scientific Report of the 2020 Dietary Guidelines Advisory Committee: Advisory Report to the Secretary of Agriculture and the Secretary of Health and Human Services. U.S. Department of Agriculture, Agricultural Research Service, Washington, DC.https://doi.org/10.52570/DGAC2020Google Scholar Given work group members’ expertise in assessment methods and surveillance systems, the following future directions from the committee were selected to anchor the work: “1) Improve dietary assessment methods that can more accurately estimate energy intakes feasible for use in federal surveillance and monitoring; and 2) Implement surveillance systems to gather more information about the contextual aspects of food and beverage intake, such as the frequency and/or timing of food and beverage consumption.”4Dietary Guidelines Advisory Committee2020. Scientific Report of the 2020 Dietary Guidelines Advisory Committee: Advisory Report to the Secretary of Agriculture and the Secretary of Health and Human Services. U.S. Department of Agriculture, Agricultural Research Service, Washington, DC.https://doi.org/10.52570/DGAC2020Google Scholar The USDA and the Department of Health and Human Services (HHS) are mandated to jointly publish the DGA every 5 years, based on the preponderance of current scientific and medical knowledge. Therefore, each new edition of the DGA relies on advancements made by the nutrition research community to address limitations and gaps in the research. The inclusion of infants and toddlers in the 2020-2025 DGA led the group to inventory and critically appraise existing tools to assess dietary practices of the B-24 population using 1 DGA recommendation as a case study. The process for identifying measurement gaps from the case study is detailed next. With a focus on measurement gaps with immediate applications for assessment methods and surveillance, the work group developed a process to identify research gaps. First, 1 key recommendation for the B-24 population was selected from the DGA to use as a model for this case study. The guideline selected was the recommendation to exclusively feed infants human milk for about the first 6 months of life or feed infants iron-fortified infant formula when human milk is unavailable.1US Departments of Agriculture and Health and Human ServicesDietary Guidelines for Americans, 2020-2025: Make every bite count with the dietary guidelines.https://www.dietaryguidelines.gov/sites/default/files/2021-03/Dietary_Guidelines_for_Americans-2020-2025.pdfDate accessed: June 9, 2022Google Scholar Next, a framework was created to characterize the full landscape of methods to measure the exclusive human milk or formula feeding dietary recommendation. Dietary intake is both multidimensional (ie, it is a complex, multilayered exposure and behavior) and dynamic (ie, it varies over time and the life course).19Reedy J. Subar A.F. George S.M. Krebs-Smith S.M. Extending methods in dietary patterns research.Nutrients. 2018; 10https://doi.org/10.3390/NU10050571Crossref Google Scholar To incorporate multidimensionality and dynamism into the approach, the following layers of multidimensionality were considered: who, what, when, where, why, how. These layers are important because they synergistically influence the "what" such that the overall combination of who, what, when, where, why, and how describes infant and toddler feeding practices. For example, a daycare provider (who) might feed a child cooked vegetables (what) at the daycare’s (where) 2 pm snack time (when) based on reimbursable meal options (why). However, multidimensional information is not captured in all dietary studies and has not been used consistently to inform dietary guidance. Nonetheless, other expert bodies have reviewed the literature and put forward evidence-based recommendations; for example, Healthy Eating Research provides recommendations for not just what but also how to feed infants and toddlers using a responsive parenting approach.20Pérez-Escamilla R. Segura-Pérez S. Lott M. Feeding guidelines for infants and young toddlers: A responsive parenting approach. Healthy Eating Research.https://healthyeatingresearch.org/wp-content/uploads/2017/02/her_feeding_guidelines_report_021416-1.pdfDate accessed: June 9, 2022Google Scholar The NCCOR B-24 Work Group identified sample research questions for all layers of multidimensionality, including who, what, when, where, why, and how. The sample research questions were mapped to existing measurement tools and methods, and measurement gaps were recorded. The work group then solicited feedback from the academic research community by consulting 3 experts with knowledge of lactation and infant nutrition, dietary assessment of children in limited resource community settings, and innovative technologies for dietary measurement (eg, wearable sensors). Two of the experts are registered dietitians, and all 3 hold PhDs in relevant fields and were identified based on their ongoing research programs. The experts were consulted to provide feedback on the research questions and measurement tools identified in Figure 1.Figure 1Sample research questions, measurement tools, measurement gaps, and innovations to fill the gap for multidimensional layers of dietary patterns for birth to 24 months (B-24). Case study: For about the first 6 months of life, exclusively feed infants human milk, or feed infants iron-fortified infant formula when human milk is unavailable. Continue to feed infants human milk through at least the first year of life and longer if desired.Sample Research QuestionMeasurement Tools AvailableaMeasurement tools included represent tools validated for research use in the B-24 population; tools developed for consumer use could be included in the future upon further evaluation and validation for research purposes in the B-24 population. Measurement tools are categorized into tools that assess diet over short time periods (ie, intake on a given day), such as one 24-hour recall; tools that assess diet over longer time periods (ie, usual frequency), such as food frequency questionnaires; and new innovative methods that can assess diet over variable time periods, such as image-based devices.Measurement Gaps and LimitationsExample of Innovation to Fill GapWhobAdditional who questions:•Who fed the infant human milk or infant formula (eg, parent, caregiver, self-feeding)?oAdditional consideration: How was self-feeding defined?•Who provided information to the parents regarding infant feeding decisions (prenatal and at birth)?•Who provided support at birth and after hospital discharge (eg, registered nurse, IBCLC, registered dietitian nutritionist, Special Supplemental Nutrition Program for Women, Infants, and Children BFPC, doulas, family, social media)?•Who provided instructions on how to prepare infant formula?•Who provided instructions on how to feed by bottle?•Who was being fed? Were there multiples? Was an older infant also being fed?Who feeds the infant human milk or infant formula (eg, parent, caregiver, self-feeding)?Short time periodsContext-specific probes not typically included to assess who feeds the infantInclude probes for who feeds the infant for each food or beverage consumed.Longer time periodsCan assess usual intake but lacks details about who is performing the feedingNovel or innovative methodsHigh respondent and researcher burden possibleUse passive video capture and face recognition software to identify who feeds the infant on each eating occasion.Who else is present during feeding (eg, other children)?Short time periodsContext-specific probes not typically included to assess who else is present during feedingInclude probes for who else is present when the infant is fed.Longer time periodsCan assess usual intake but lacks details about who is present during feedingNovel or innovative methodsHigh respondent and researcher burden possibleAdapt Exposure Notification Systems (currently used to map potential COVID-19 exposure with cell phone proximity) to identify who was present at the feeding.WhatcAdditional what questions:•What was the quality of human milk fed to the infant? For example, what was the diet quality of the lactating parent? For expressed human milk, what storage practices were used?•Was there mixed feeding?oAdditional consideration: How did the ratio of infant formula to human milk change in the child’s first year of life? What was the intensity, proportion, or amount of human milk consumed by mixed fed infants?•Was human milk ever fed?•If infant formula was consumed, what type (eg, iron-fortified, milk-based, soy-based, homemade—not recommended)?•Was the infant fed fresh pumped milk or previously frozen milk?•What supplement(s) was the infant consuming? What supplement(s) was the lactating parent consuming?•Was toddler formula consumed? If so, what type?•What ways was the milk or formula fortified by the caregiver (eg, with supplements, cereal, sugar)?What was the first feeding after birth?Short time periodsSmall window of opportunity to collect data on first feeding after birthStandardize use of electronic medical records to integrate with data collected on birth certificate.Collect data at hospital discharge or at first postnatal pediatric appointment.Longer time periodsReporting errors may occur; this option relies on accurate recall of the first feeding after birthAdjust for measurement error and social desirability bias when possible.Is there mixed feeding? If so, what is the ratio of human milk feeding to infant formula?Short time periodsCan assess what was fed (eg, human milk vs formula) but volume of human milk expression is difficult to measureAdd probes to capture mixed feeding occasions and quantities consumed.Longer time periodsCan assess usual intake but lacks details about quantities fedDevelop apps that objectively yet passively collect this information to reduce respondent reporting burden. Conduct user testing on smartphone apps to ensure intuitive user interface to maximize ease of use and reduce missing data.Novel or innovative methodsBiomarkers: expensive, moderate risk diagnostic tools exist but few are validated for B-24 populationLeverage carbon isotope ratios to tease apart human milk from formula intake.WhendAdditional when questions:•What was the duration of human milk consumption?oAdditional consideration: Did it continue beyond 24 months of age?•What was the duration of exclusive human milk consumption?•When was the first time something other than human milk was introduced? When were foods introduced for taste? When were foods introduced for nutritive feeding that displaced energy from milk or formula?•What was the timing of feeding across the day? How did it evolve over the first year of life?When was the first feeding after birth?Short time periodsMeasurement error for recalling time of eating is not well characterizedCombine multiple methods of dietary assessment to understand measurement error of time reporting.Longer time periodsNot well suited to capture this type of informationNovel or innovative methodsHigh respondent and researcher burden possibleApply ecological momentary assessment or adapt or expand electronic medical records to capture infant feeding behavior during birth hospitalization (ie, hourly data collections).What is the duration of human milk consumption?Short time periodsSingle administration not well suited to capture this type of informationLonger time periodsNot well suited to capture this type of informationNovel or innovative methodsHigh respondent and researcher burden possibleApply ecological momentary assessment and develop programs to query and capture information on duration of human milk consumption.WhereeAdditional where questions:•Where did the infant receive human milk vs infant formula?•Where was the human milk or formula obtained (eg, lactating parent, milk bank, friend, social media, store)?•Where did the parent or caregiver obtain early infant feeding information and support?•Where did the birth occur (eg, hospital, at home, birthing center, car)?Where is the infant typically fed?Short time periodsContext-specific probes not typically included for location of feedingFor each food or beverage consumed, ask where the infant is fed.Longer time periodsCan assess “usual” but can lack detail on where the food was consumedNovel or innovative methodsHigh respondent and researcher burden possibleUse room cameras to capture where the infant is fed.Pair phone GPS of the primary feeder with infant feeding reports.WhyfAdditional why questions:•If the infant was not exclusively fed human milk, why was formula introduced?oAdditional considerations: Probe about source of beliefs. For example, why did they feel the infant was not satisfied?If the infant was not exclusively fed human milk, why was formula introduced?Short time periodsNot well suited to capture this type of informationLonger time periodsNot well suited to capture this type of informationNovel or innovative methodsNot well suited to capture this type of informationHowgAdditional how questions:•How did type of infant formula fed change over the first year (if it does change)?•How did we assess responsive feeding or feeding on demand for human milk vs formula feeding?•How was infant formula prepared and stored?•How was expressed human milk prepared (including warmed) and stored (including duration of storage)? Was the human milk expressed in the morning and fed later in the day? Was it frozen and fed days, weeks, or months later?•How did time impact feeding practices? Were parents trying to align with “chronobiology”? What was the clinical relevance of observed chronobiological shifts in human milk composition? What were the unintended consequences of trying to align with chronobiology in terms of caregiver burden?•Was the infant fed on demand vs on a schedule?•How was the infant held or positioned during feeding?•When introducing complementary foods, in what order was human milk or complementary foods fed within the feeding session?•How did the infant interact with the feeder during the eating occasion?How is the human milk fed to the infant: from the chest, bottle, or other device?Short time periodsContext-specific probes not included for how the milk or formula was administeredAt each feeding, ask how human milk was fed.Longer time periodsCan assess “usual” intake (what) but often lacks questions about behavioral feeding patterns (how)Include questions to clarify how the human milk or infant formula was administered.Novel or innovative methodsHigh respondent and researcher burden possibleUse room cameras, body cameras, smart bottles, or other devices to capture feeding details and pair with short-term methods.a Measurement tools included represent tools validated for research use in the B-24 population; tools developed for consumer use could be included in the future upon further evaluation and validation for research purposes in the B-24 population. Measurement tools are categorized into tools that assess diet over short time periods (ie, intake on a given day), such as one 24-hour recall; tools that assess diet over longer time periods (ie, usual frequency), such as food frequency questionnaires; and new innovative methods that can assess diet over variable time periods, such as image-based devices.b Additional who questions:•Who fed the infant human milk or infant formula (eg, parent, caregiver, self-feeding)?oAdditional consideration: How was self-feeding defined?•Who provided information to the parents regarding infant feeding decisions (prenatal and at birth)?•Who provided support at birth and after hospital discharge (eg, registered nurse, IBCLC, registered dietitian nutritionist, Special Supplemental Nutrition Program for Women, Infants, and Children BFPC, doulas, family, social media)?•Who provided instructions on how to prepare infant formula?•Who provided instructions on how to feed by bottle?•Who was being fed? Were there multiples? Was an older infant also being fed?c Additional what questions:•What was the quality of human milk fed to the infant? For example, what was the diet quality of the lactating parent? For expressed human milk, what storage practices were used?•Was there mixed feeding?oAdditional consideration: How did the ratio of infant formula to human milk change in the child’s first year of life? What was the intensity, proportion, or amount of human milk consumed by mixed fed infants?•Was human milk ever fed?•If infant formula was consumed, what type (eg, iron-fortified, milk-based, soy-based, homemade—not recommended)?•Was the infant fed fresh pumped milk or previously frozen milk?•What supplement(s) was the infant consuming? What supplement(s) was the lactating parent consuming?•Was toddler formula consumed? If so, what type?•What ways was the milk or formula fortified by the caregiver (eg, with supplements, cereal, sugar)?d Additional when questions:•What was the duration of human milk consumption?oAdditional consideration: Did it continue beyond 24 months of age?•What was the duration of exclusive human milk consumption?•When was the first time something other than human milk was introduced? When were foods introduced for taste? When were foods introduced for nutritive feeding that displaced energy from milk or formula?•What was the timing of feeding across the day? How did it evolve over the first year of life?e Additional where questions:•Where did the infant receive human milk vs infant formula?•Where was the human milk or formula obtained (eg, lactating parent, milk bank, friend, social media, store)?•Where did the parent or caregiver obtain early infant feeding information and support?•Where did the birth occur (eg, hospital, at home, birthing center, car)?f Additional why questions:•If the infant was not exclusively fed human milk, why was formula introduced?oAdditional considerations: Probe about source of beliefs. For example, why did they feel the infant was not satisfied?g Additional how questions:•How did type of infant formula fed change over the first year (if it does change)?•How did we assess responsive feeding or feeding on demand for human milk vs formula feeding?•How was infant formula prepared and stored?•How was expressed human milk prepared (including warmed) and stored (including duration of storage)? Was the human milk expressed in the morning and fed later in the day? Was it frozen and fed days, weeks, or months later?•How did time impact feeding practices? Were parents trying to align with “chronobiology”? What was the clinical relevance of observed chronobiological shifts in human milk composition? What were the unintended consequences of trying to align with chronobiology in terms of caregiver burden?•Was the infant fed on demand vs on a schedule?•How was the infant held or positioned during feeding?•When introducing complementary foods, in what order was human milk or complementary foods fed within the feeding session?•How did the infant interact with the feeder during the eating occasion?