1 Survey

Appendix A A.2.1.k–11

Version 01/18/2007

Source: FDA Infant Feeding Practices Study Neonatal Questionnaire Visits: 1 month Mode: Self-administered (Mail in) Estimated Time: 10 minutes		BAR CODE LABEL OR SUBJECT ID HERE |___|___|___|___|___|___|___|___|

National Children’s Study

Infant Feeding Questionnaire—1 Month

PROTECTION OF PRIVACY STATEMENT INSERTED HERE

NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx*). Do not return the completed form to this address.

Please complete this questionnaire within 2 weeks and mail it in the large pre‑stamped envelope to:

LABEL FOR CLINICAL CENTER RETURN ADDRESS

G eneral Instructions

This questionnaire is about your 1-month-old infant __________________. When we refer to “your baby,” please respond with this 1-month old child in mind.

This questionnaire asks you about your baby’s recent diet.

Answer each question as best you can. Estimate if you are not sure. A guess is better than leaving a blank.

If your baby is regularly cared for by someone else, it is very important that you ask your child care provider to give you information to answer the questions.

Use only a black ball-point pen. Do not use a pencil or felt-tip pen. Do not fold, staple, or tear the pages.

P ut an X in the box next to your answer.

If you make any changes, cross out the incorrect answer and put an X in the box next to the correct answer. Also draw a circle around the correct answer.

BEFORE YOU BEGIN, PLEASE FILL IN TODAY’S DATE:

__ __/__ __/__ __

Month Day Year

1. While you were in the hospital or birthing center was your baby fed water, formula, or sugar water at any time?

	Yes	No	Don’t know
Water?
Formula?
Sugar water?

2. When you left the hospital or birthing center, how were you feeding your baby?

Breast milk only

Formula only

Both breast milk and formula

3. In the past 7 days, how often was your baby fed each item listed below? Include feedings by everyone who feeds the baby and include snacks and night-time feedings.

If your baby was fed the item once a day or more, write the number of feedings per day in the first column. If your baby was fed the item less than once a day, write the number of feedings per week in the second column. Fill in only one column for each item. If your baby was not fed the item at all during the past 7 days, write 0 in the second column.

	Feedings per Day	Feedings per Week
Breast milk (include breast fed and expressed or pumped breast milk)?	_______	_______
Formula?
Water?	_______	_______
Sugar water?	_______	_______
Cow’s milk?	_______	_______
Other milk (soy milk, rice milk, goat milk)?	_______	_______
100% fruit juice or 100% vegetable juice?	_______	_______
Sweet drinks (juice drinks, soft drinks, soda, sweet tea, Kool-Aid)?	_______	_______
Baby cereal?	_______	_______
Other (PLEASE SPECIFY)­­­­­____________________	_______	_______

If your baby is not drinking breast milk now, but was ever fed breast milk  GO TO QUESTION 4.

If your baby is drinking breast milk now  GO TO QUESTION 5

If your baby was never fed breast milk GO TO QUESTION 11

4. How old was your baby when you completely stopped breastfeeding and pumping or expressing breast milk?

Age in days (if younger than two weeks) _________

Age in weeks (if older than two weeks) _________

5. Have you ever fed your baby pumped or expressed breast milk?

Yes GO TO QUESTION 6

No GO TO QUESTION 11

6. In the past 7 days, about how often was your baby fed pumped or expressed breast milk? Include feedings by everyone who feeds the baby and include snacks and nighttime feedings.

1 time per week

2 to 4 times per week

Nearly every day

1 time per day

2 to 3 times per day

4 to 6 times per day

More than 6 times per day

7. In the past 7 days, about how long was your breast milk usually stored in the refrigerator before it was fed to your baby? (Include cooler with cold source such as freezer packs).

1 day or less

2–3 days

4–5 days

6–8 days

More than 8 days

DID NOT STORE BREAST MILK IN REFRIGERATOR …

8. In the past 7 days, about how long was your breast milk usually kept at room temperature and then fed to your baby?

1 hour or less

1–2 hours

3–4 hours

5–8 hours

9–11 hours

12–16 hours

More than 16 hours

DON’T KEEP MILK AT ROOM TEMPERATURE

9. Now think about how you clean the bottle nipples used to feed pumped or expressed breast milk to your baby. In the past 7 days, did you never, sometimes, most of the time, or always:

	Never	Sometimes	Most of the time	Always
a. Rinse the nipples with water only before a feeding?
b. Wash the nipples in an automatic dishwasher?
c. Wash the nipples by hand with dish detergent?
d. Boil or sterilize the nipples?
e. Not clean the nipples between feedings (use nipples to feed more milk without rinsing or washing)?

10. Now think about how you cleaned your breast milk collection pump kit, the container used to collect the breast milk, and the container used to store the milk. During the past 7 days, how often was each item oiled, sterilized in a microwave, sterilized with a chemical dip, or washed in a dishwasher?

	After each use	Once a day	Every 2 to 6 days	About once a week	About once in 2 weeks	Never	Item is disposable
a. Pump collection kit and breast milk collection container
b. Container used to store milk

11. How old was your baby when (he/she) was first fed formula on a daily basis?

Never fed formula Go to Question 22

1 day or less

2 to 6 days

7 to 13 days

14 to 20 days

More than 20 days

12. What kind of infant formula was your baby fed in the past 7 days? Infant formulas are listed alphabetically along with a group number in the chart below. Please put an X in the box next to the group number of each infant formula your baby was fed. (MARK ALL THAT APPLY)

Never fed formula Go to Question 22

Group 1 Group 4 ………

Group 2 Group 5 ………

Group 3 Group 6 ………

FORMULA	Group		FORMULA	Group
EleCare	1		Nestle Good Start Essentials	2
Enfamil	2		Nestle Good Start 2 Essentials	2
Enfamil AR LIPIL	3		Nestle Good Start Essentials Soy	5
Enfamil Gentlease LIPIL	3		Nestle Good Start 2 Essentials Soy	5
Enfamil LactoFree LIPIL	3		Nestle Good Start Essentials Soy DHA and ARA	4
Enfamil LIPIL	3		Nestle Good Start Supreme	2
Enfamil Next Step LIPIL….	3		Nestle Good Start Supreme DHA and ARA	3
Enfamil Next Step ProSobee LIPIL	4		Nestle Good Stat Supreme 2 DHA and ARA	3
Enfamil ProSobee	5		Nestle NAN DHA and ARA	3
Enfamil ProSobee LIPIL	4		Similac	2
Enfamil Nutramigen LIPIL	6		Smiliac Advance	3
Enfamil Pregestimil	6		Similac 2	2
Horizon Organic	2		Similac 2 Advance	3
Isomil	5		Similac Alimentum Advance	6
Isomil Advance	4		Similac Lactose Free Advance	3
Isomil 2	5		Similac Neosure Advance	3
Isomil 2 Advance	4		Store Brand milk based without DHA and ARA	2
Isomil DF	5		Store brand milk based with DHA and ARA LIPID	3
			Store brand soy based without DHA and ARA	5
			Store brand soy based with DHA and ARA LIPID	4

13. Was the formula with iron or a low iron formula?

With iron

Low iron

14. Was the formula ready-to-feed, liquid concentrate, powder from a can that makes a single serving, or powder from single serving packets? (MARK ALL THAT APPLY)

Ready-to-feed

Liquid concentrate

Powder from a can that makes more than one bottle

Powder from single serving packets

If your baby was fed only ready-to-feed formula, go to question 19. If your baby was fed any liquid concentrate or powdered formula, go to question 15.

15. When the formula was mixed, was it made according to the directions on the formula label?

Yes……….. GO TO QUESTION 18

No…………  When the formula was mixed, how much formula and how much water were used?

	Amount	Measurement Unit
Formula	_______________	Tablespoon Teaspoon Ounce Cup Packet Formula Can
Water	_______________	Ounces Cups Formula Can

16. During the past 7 days, what types of water have you and others who care for your baby used for mixing your baby’s formula? (MARK ALL THAT APPLY)

Tap water from the cold faucet

Warm tap water from the hot faucet

Bottled water

No water used, fed Ready-to-Feed formula

17. Was the water used to mix the formula boiled?

Yes

No

18. In the past 7 days, on the average, how many ounces of formula did your baby drink at each feeding?

____________________ Ounces

19. Now think about how you clean the bottle nipples used to feed formula to your baby. In the past 7 days, did you never, sometimes, most of the time, or always:

	Never	Sometimes	Most of the time	Always
a. Rinse the nipples with water only before a feeding?
b. Wash the nipples in an automatic dishwasher?
c. Wash the nipples by hand with dish detergent?
d. Boil or sterilize the nipples?
e. Not clean the nipples between feedings (use nipples to feed more milk without rinsing or washing)

20. Now think about how you cleaned your hands when you were preparing formula. During the past 7 days, did you never, sometimes, most of the time, or always:

	Never	Sometimes	Most of the time	Always
a. Rinse hands with water only?
b. Wipe hands only?
c. Wash hands with soap?
d. Use a hand sanitizer (such as gel or wipes)?
e. Prepare formula without cleaning your hands?

21. In the past 7 days, about how long were the bottles of prepared formula kept at room temperature and then fed to your baby?

1 hour or less

1–2 hours

3–4 hours

5–8 hours

9–11 hours

12–16 hours

M
ore than 16 hours

NEVER

22. In the past 7 days, about how often did your baby drink from each of
the following types of bottles or cups?

	Never	Sometimes	Most of the time	Always
a. Plastic baby bottle with disposable bottle liner?
b. Plastic baby bottle without disposable liner?
c. Other plastic bottle (for example, a water bottle)?
d. Glass baby bottle?
e. Plastic “no spill” cup?

23. Has your baby used a pacifier in the past 7 days?

Yes

No

24. Have you ever fed your baby fruit juice that was not sold especially for babies?

Yes GO TO QUESTION 25

No GO TO QUESTION 26

25. About how often was the fruit juice fortified with calcium?

Always

Sometimes

Rarely

Never

Don’t know

26. Has your baby ever been fed cow’s milk that was not sold especially for babies? (This includes whole, lowfat, nonfat, or chocolate milk.)

Yes GO TO QUESTION 27

No GO TO QUESTION 28

27. How old was your baby when he/she was first fed cow’s milk that was not sold especially for babies?

Age in weeks _________

28. Which of the following supplements was your child given at least three days a week
during the past 2 weeks? (MARK ALL THAT APPLY)

F luoride

Iron

Vitamin D

Other vitamins or supplements:
Specify ________________________________

None

2 9. Were the supplements you gave your baby in the form of drops or pills?
[NOTE: MARK CRUSHED PILLS MIXED WITH LIQUID AS PILLS.]

Drops

Pills

Thank you very much for completing this questionnaire!

All of your answers are very important.

Please help us by looking at each page again to make sure that you:

Did not skip any pages and

Crossed out the wrong answer and circled the right answer if you made any changes.

Thank you for continuing to be part of
the National Children’s Study.

Source: FDA Infant Feeding Practices Study Neonatal Questionnaire Visits: 6 month Mode: Self-administered (Mail in) Estimated Time: 10 minutes		BAR CODE LABEL OR SUBJECT ID HERE |___|___|___|___|___|___|___|___|

National Children’s Study

Infant Feeding Questionnaire—6 Months

PROTECTION OF PRIVACY STATEMENT INSERTED HERE

NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx*). Do not return the completed form to this address.

Please complete this questionnaire within 2 weeks and mail it in the large pre‑stamped envelope to:

LABEL FOR CLINICAL CENTER RETURN ADDRESS

G eneral Instructions

This questionnaire is about your 6-month-old infant __________________. When we refer to “your baby,” please respond with this 6-month old infant in mind.

This questionnaire asks you about your baby’s recent diet.

Answer each question as best you can. Estimate if you are not sure. A guess is better than leaving a blank.

If your baby is regularly cared for by someone else, it is very important that you ask your child care provider to give you information to answer the questions.

Use only a black ball-point pen. Do not use a pencil or felt-tip pen. Do not fold, staple, or tear the pages.

P ut an X in the box next to your answer.

If you make any changes, cross out the incorrect answer and put an X in the box next to the correct answer. Also draw a circle around the correct answer.

BEFORE YOU BEGIN, PLEASE FILL IN TODAY’S DATE:

__ __/__ __/__ __

Month Day Year

1. In the past 7 days, how often was your baby fed each item listed below? Include feedings by everyone who feeds the baby and include snacks and night-time feedings.

If your baby was fed the item once a day or more, write the number of feedings per day in the first column. If your baby was fed the item less than once a day, write the number of feedings per week in the second column. Fill in only one column for each item. If your baby was not fed the item at all during the past 7 days, write 0 in the second column.

	Feedings per Day	Feedings per Week
a. Breast milk (include breast fed and expressed or pumped breast milk)?	_______	_______
b. Formula?	_______	_______
c. Cow’s milk?	_______	_______
d. Other milk (soy milk, rice milk, goat milk)?	_______	_______

If your baby is not drinking breast milk now, but was ever fed breast milk  GO TO QUESTION 2.

If your baby is drinking breast milk now  GO TO QUESTION 3.

If your baby was never fed breast milk GO TO QUESTION 9.

2. How old was your baby when you completely stopped breastfeeding and pumping or expressing breast milk?

Age in weeks (if younger than 1 month) _________

Age in months (if older than 1 month) __________

3. Have you ever fed your baby pumped or expressed breast milk?

Yes GO TO QUESTION 4

No GO TO QUESTION 9

4. In the past 7 days, about how often was your baby fed pumped or expressed breast milk? Include feedings by everyone who feeds the baby and include snacks and nighttime feedings.

1 time per week

2 to 4 times per week

Nearly every day

1 time per day

2 to 3 times per day

4 to 6 times per day

More than 6 times per day

5. In the past 7 days, about how long was your breast milk usually stored in the refrigerator before it was fed to your baby? (Include cooler with cold source such as freezer packs).

1 day or less

2–3 days

4–5 days

6–8 days

More than 8 days

DID NOT STORE BREAST MILK IN REFRIGERATOR …

6. In the past 7 days, about how long was your breast milk usually kept at room temperature and then fed to your baby?

1 hour or less

1–2 hours

3–4 hours

5–8 hours

9–11 hours

12–16 hours

More than 16 hours

DID NOT KEEP MILK AT ROOM TEMPERATURE

7. Now think about how you clean the bottle nipples used to feed pumped or expressed breast milk to your baby. In the past 7 days, did you never, sometimes, most of the time, or always:

	Never	Sometimes	Most of the time	Always
a. Rinse the nipples with water only before a feeding?
b. Wash the nipples in an automatic dishwasher?
c. Wash the nipples by hand with dish detergent?
d. Boil or sterilize the nipples?
e. Not clean the nipples between feedings (use nipples to feed more milk without rinsing or washing)

8. Now think about how you cleaned your breast milk collection pump kit, the container used to collect the breast milk, and the container used to store the milk. During the past 7 days, how often was each item oiled, sterilized in a microwave, sterilized with a chemical dip or washed in a dishwasher?

	After each use	Once a day	Every 2 to 6 days	About once a week	About once in 2 weeks	Never	Item is disposable
a. Pump collection kit and breast milk collection container
b. Container used to store milk

9. How old was your baby when (he/she) was first fed formula on a daily basis?

Never fed formula Go to Question 20

Less than 1 month old

1 to 2 months old

3 to 4 months old

5 to 6 months old

More than 6 months old

10. What kind of infant formula was your baby fed in the past 7 days? Infant formulas are listed alphabetically along with a group number in the chart below. Please put an X in the box next to the group number of each infant formula your baby was fed. (MARK ALL THAT APPLY)

Never fed formula Go to Question 20

Group 1 Group 4 ………

Group 2 Group 5 ………

Group 3 Group 6 ………

FORMULA NAME	Group Number		FORMULA NAME	Group Number
EleCare	1		Nestle Good Start Essentials	2
Enfamil	2		Nestle Good Start 2 Essentials	2
Enfamil AR LIPIL	3		Nestle Good Start Essentials Soy	5
Enfamil Gentlease LIPIL	3		Nestle Good Start 2 Essentials Soy	5
Enfamil LactoFree LIPIL	3		Nestle Good Start Essentials Soy DHA and ARA	4
Enfamil LIPIL	3		Nestle Good Start Supreme	2
Enfamil Next Step LIPIL….	3		Nestle Good Start Supreme DHA and ARA	3
Enfamil Next Step ProSobee LIPIL	4		Nestle Good Stat Supreme 2 DHA and ARA	3
Enfamil ProSobee	5		Nestle NAN DHA and ARA	3
Enfamil ProSobee LIPIL	4		Similac	2
Enfamil Nutramigen LIPIL	6		Smiliac Advance	3
Enfamil Pregestimil	6		Similac 2	2
Horizon Organic	2		Similac 2 Advance	3
Isomil	5		Similac Alimentum Advance	6
Isomil Advance	4		Similac Lactose Free Advance	3
Isomil 2	5		Similac Neosure Advance	3
Isomil 2 Advance	4		Store Brand milk based without DHA and ARA	2
Isomil DF	5		Store brand milk based with DHA and ARA LIPID	3
			Store brand soy based without DHA and ARA	5
			Store brand soy based with DHA and ARA LIPID	4

11. Was the formula with iron or a low iron formula?

With iron

Low iron

12. Was the formula ready-to-feed, liquid concentrate, powder from a can that makes a single serving, or powder from single serving packets? (MARK ALL THAT APPLY)

Ready-to-feed

Liquid concentrate

Powder from a can that makes more than one bottle

Powder from single serving packets

If your baby was fed ready-to-feed formula ONLY, go to question 16. If your baby was fed any liquid concentrate or powdered formula, go to question 13.

13. When the formula was mixed, was it made according to the directions on the formula label?

Yes……….. GO TO QUESTION 14

No…………  When the formula was mixed, how much formula and how much water were used?

	Amount	Measurement Unit
Formula	_______________	Tablespoon Teaspoon Ounce Cup Packet Formula Can
Water	_______________	Ounces Cups Formula Can

14. During the past 7 days, what types of water have you and others who care for your baby used for mixing your baby’s formula? (MARK ALL THAT APPLY)

Tap water from the cold faucet

Warm tap water from the hot faucet

Bottled water

No water used, fed ready-to-feed formula

15. Was the water used to mix the formula boiled?

Yes

No

16. In the past 7 days, on the average, how many ounces of formula did your baby drink at each feeding?

____________________ Ounces

17. Now think about how you clean the bottle nipples used to feed formula to your baby. In the past 7 days, did you never, sometimes, most of the time, or always:

	Never	Sometimes	Most of the time	Always
a. Rinse the nipples with water only before a feeding?
b. Wash the nipples in an automatic dishwasher?
c. Wash the nipples by hand with dish detergent?
d. Boil or sterilize the nipples?
e. Not clean the nipples between feedings (use nipples to feed more milk without rinsing or washing).

18. Now think about how you cleaned your hands when you were preparing formula. During the past 7 days, did you never, sometimes, most of the time, or always:

	Never	Sometimes	Most of the time	Always
a. Rinse hands with water only?
b. Wipe hands only?
c. Wash hands with soap?
d. Use a hand sanitizer (such as gel or wipes)?
e. Prepare formula without cleaning your hands?

19. In the past 7 days, about how long were the bottles of prepared formula kept at room temperature and then fed to your baby?

1 hour or less

1–2 hours

3–4 hours

5–8 hours

9–11 hours

12–16 hours

M
ore than 16 hours

NEVER

20. In the past 7 days, about how often did your baby drink from each of the following types of bottles and cups?

	Never	Sometimes	Most of the time	Always
a. Plastic baby bottle with disposable bottle liner?
b. Plastic baby bottle without disposable liner?
c. Other plastic bottle (for example, a water bottle)?
d. Glass baby bottle?
e. Plastic “no spill” cup?

21. Has your baby used a pacifier in the past 7 days?

Yes

No

22. Has your baby ever been fed cow’s milk that was not sold especially for babies? (This includes whole, lowfat, nonfat, or chocolate milk.)

Yes GO TO QUESTION 23

No GO TO QUESTION 24

23. How old was your baby when he/she was first fed cow’s milk that was not sold especially for babies?

Age in months _________

24. Have you ever fed your baby fruit juice that was not sold especially for babies?

Yes GO TO QUESTION 25

No GO TO QUESTION 26

25. About how often was the fruit juice fortified with calcium?

Always

Sometimes

Rarely

Never

Don’t know

2
6. Now think about fruits, vegetables, and meats that may have been fed to your baby in the past 7 days. How much of each type of food your baby ate was commercial baby food?

(Commercial baby food is food sold for babies. Foods that are NOT commercial baby food are table foods your whole family eats, foods you made especially for your baby, fresh fruit, and fruit juices that are not sold especially for babies.)

Type of Commercial Baby Food	Always	Usually	Sometimes	Never	Not fed to my baby
a. Fruit and vegetable juice?
b. Fruit?
c. Vegetables?
d. Meats, chicken and turkey?
e. Combination dinners (for example Spaghetti Dinner, Pasta and Vegetable Dinner, Turkey and Rice Dinner)?

27. During the past 7 days, were the baby foods your baby ate always, sometimes, rarely, or never organic baby foods?

Always

Sometimes

Rarely

Never

Don’t know

28. Which of the following supplements was your child given at least three days a week
during the past 2 weeks? (MARK ALL THAT APPLY)

F luoride

Iron

Vitamin D

Other vitamins or supplements:
Specify ________________________________

None

29. Were the supplements you gave your baby in the form of drops or pills?
[NOTE: MARK CRUSHED PILLS MIXED WITH LIQUID AS PILLS.]

Drops

Pills

30. Was your baby given and herbal or botanical preparations or any kind of tea or home remedy in the past 7 days? Do not count preparations put on the baby’s skin or anything the baby may have gotten from breast milk after you took an herbal or botanical preparation.

Yes GO TO QUESTION 31

No GO TO LAST PAGE

31. Please write in the name of all of the kinds of herbal or botanical preparations or teas your baby was given in the past 7 days.

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Thank you very much for completing this questionnaire!

All of your answers are very important.

Please help us by looking at each page again to make sure that you:

Did not skip any pages and

Crossed out the wrong answer and circled the right answer if you made any changes.

Thank you for continuing to be part of
the National Children’s Study.

Source: FDA Infant Feeding Practices Study Neonatal Questionnaire Visits: 6 month Mode: Self-administered (Mail in) Estimated Time: 10 minutes		BAR CODE LABEL OR SUBJECT ID HERE |___|___|___|___|___|___|___|___|

National Children’s Study

Infant Feeding Questionnaire—12 Months

PROTECTION OF PRIVACY STATEMENT INSERTED HERE

NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx*). Do not return the completed form to this address.

Please complete this questionnaire within 2 weeks and mail it in the large pre‑stamped envelope to:

LABEL FOR CLINICAL CENTER RETURN ADDRESS

G eneral Instructions

This questionnaire is about your 12-month-old infant __________________. When we refer to “your baby,” please respond with this 12-month old infant in mind.

This questionnaire asks you about your baby’s recent diet.

Answer each question as best you can. Estimate if you are not sure. A guess is better than leaving a blank.

If your baby is regularly cared for by someone else, it is very important that you ask your child care provider to give you information to answer the questions.

Use only a black ball-point pen. Do not use a pencil or felt-tip pen. Do not fold, staple, or tear the pages.

P ut an X in the box next to your answer.

If you make any changes, cross out the incorrect answer and put an X in the box next to the correct answer. Also draw a circle around the correct answer.

BEFORE YOU BEGIN, PLEASE FILL IN TODAY’S DATE:

__ __/__ __/__ __

Month Day Year

1. In the past 7 days, how often was your baby fed each item listed below? Include feedings by everyone who feeds the baby and include snacks and night-time feedings.

If your baby was fed the item once a day or more, write the number of feedings per day in the first column. If your baby was fed the item less than once a day, write the number of feedings per week in the second column. Fill in only one column for each item. If your baby was not fed the item at all during the past 7 days, write 0 in the second column.

	Feedings per Day	Feedings per Week
a. Breast milk (include breast fed and expressed or pumped breast milk)?	_______	_______
b. Formula?	_______	_______
c. Cow’s milk?	_______	_______
d. Other milk (soy milk, rice milk, goat milk)?	_______	_______

If your baby is not drinking breast milk now, but was ever fed breast milk  GO TO QUESTION 2.

If your baby is drinking breast milk now  GO TO QUESTION 3

If your baby was never fed breast milk GO TO QUESTION 5.

2. How old was your baby when you completely stopped breastfeeding and pumping or expressing breast milk?

Age in weeks (if younger than 1 month) _________

Age in months (if older than 1 month) __________

3. Have you ever fed your baby pumped or expressed breast milk?

Yes GO TO QUESTION 4

No GO TO QUESTION 5

4. In the past 7 days, about how often was your baby fed pumped or expressed breast milk? Include feedings by everyone who feeds the baby and include snacks and nighttime feedings.

1 time per week

2 to 4 times per week

Nearly every day

1 time per day

2 to 3 times per day

4 to 6 times per day

More than 6 times per day

5. How old was your baby when (he/she) was first fed formula on a daily basis?

Never fed formula Go to Question 13

Less than 1 month old

1 to 2 months old

3 to 4 months old

5 to 6 months old

More than 6 months old

6. What kind of infant formula was your baby fed in the past 7 days? Infant formulas are listed alphabetically along with a group number in the chart below. Please put an X in the box next to the group number of each infant formula your baby was fed. (MARK ALL THAT APPLY)

Never fed formula Go to Question 24

Group 1 Group 4 ………

Group 2 Group 5 ………

Group 3 Group 6 ………

FORMULA NAME	Group Number		FORMULA NAME	Group Number
EleCare	1		Nestle Good Start Essentials	2
Enfamil	2		Nestle Good Start 2 Essentials	2
Enfamil AR LIPIL	3		Nestle Good Start Essentials Soy	5
Enfamil Gentlease LIPIL	3		Nestle Good Start 2 Essentials Soy	5
Enfamil LactoFree LIPIL	3		Nestle Good Start Essentials Soy DHA and ARA	4
Enfamil LIPIL	3		Nestle Good Start Supreme	2
Enfamil Next Step LIPIL….	3		Nestle Good Start Supreme DHA and ARA	3
Enfamil Next Step ProSobee LIPIL	4		Nestle Good Stat Supreme 2 DHA and ARA	3
Enfamil ProSobee	5		Nestle NAN DHA and ARA	3
Enfamil ProSobee LIPIL	4		Similac	2
Enfamil Nutramigen LIPIL	6		Smiliac Advance	3
Enfamil Pregestimil	6		Similac 2	2
Horizon Organic	2		Similac 2 Advance	3
Isomil	5		Similac Alimentum Advance	6
Isomil Advance	4		Similac Lactose Free Advance	3
Isomil 2	5		Similac Neosure Advance	3
Isomil 2 Advance	4		Store Brand milk based without DHA and ARA	2
Isomil DF	5		Store brand milk based with DHA and ARA LIPID	3
			Store brand soy based without DHA and ARA	5
			Store brand soy based with DHA and ARA LIPID	4

7. Was the formula with iron or a low iron formula?

With iron

Low iron

8. Was the formula ready-to-feed, liquid concentrate, powder from a can that makes a single serving, or powder from single serving packets? (MARK ALL THAT APPLY)

Ready-to-feed

Liquid concentrate

Powder from a can that makes more than one bottle

Powder from single serving packets

If you fed your baby ready-to-feed formula ONLY, go to question 10. If you fed your baby any liquid concentrate or powdered formula go to question 6.

8. When the formula was mixed, was it made according to the directions on the formula label?

Yes……….. GO TO QUESTION 14

No…………  When the formula was mixed, how much formula and how much water were used?

	Amount	Measurement Unit
Formula	_______________	Tablespoon Teaspoon Ounce Cup Packet Formula Can
Water	_______________	Ounces Cups Formula Can

10. During the past 7 days, what types of water have you and others who care for your baby used for mixing your baby’s formula? (MARK ALL THAT APPLY)

Tap water from the cold faucet

Warm tap water from the hot faucet

Bottled water

No water used, fed ready-to-feed formula

11. Was the water used to mix the formula boiled?

Yes

No

12. In the past 7 days, on the average, how many ounces of formula did your baby drink at each feeding?

____________________ Ounces

13. In the past 7 days, about how often did your baby drink from each of the following types of bottles and cups?

	Never	Sometimes	Most of the time	Always
a. Plastic baby bottle with disposable bottle liner?
b. Plastic baby bottle without disposable liner?
c. Other plastic bottle (for example, a water bottle)?
d. Glass baby bottle?
e. Plastic “no spill” cup?

14. Has your baby used a pacifier in the past 7 days?

Yes

No

15. Has your baby ever been fed cow’s milk that was not sold especially for babies? (This includes whole, lowfat, nonfat, or chocolate milk.)

Yes GO TO QUESTION 16

No GO TO QUESTION 17

16. How old was your baby when he/she was first fed cow’s milk that was not sold especially for babies?

Age in months _________

17. Have you ever fed your baby fruit juice that was not sold especially for babies?

Yes GO TO QUESTION 18

No GO TO QUESTION 19

18. About how often was the fruit juice fortified with calcium?

Always

Sometimes

Rarely

Never

Don’t know

19. How old was your baby when he/she was first fed cereal, including baby cereal on a daily basis?

Never fed cereal

Less than 1 month old

1 to 2 months old

3 to 4 months old

5 to 6 months old

More than 6 months old

20. How old was your baby when he/she was first fed pureed baby food on a daily basis? PLEASE INCLUDE COMMERCIAL (STORE BOUGHT) AND HOMEMADE BABY FOOD.

Never fed pureed baby food

Less than 1 month old

1 to 2 months old

3 to 4 months old

5 to 6 months old

More than 6 months old

21. How old was your baby when he/she was first fed table food such as eggs, cheese, or potatoes on a daily basis?

Never fed table food

Less than 1 month old

1 to 2 months old

3 to 4 months old

5 to 6 months old

More than 6 months old

2
2. Now think about fruits, vegetables, and meats that may have been fed to your baby in the past 7 days. How much of each type of food your baby ate was commercial baby food?

(Commercial baby food is food sold for babies. Foods that are NOT commercial baby food are table foods your whole family eats, foods you made especially for your baby, fresh fruit, and fruit juices that are not sold especially for babies.)

Type of Commercial Baby Food	Always	Usually	Sometimes	Never	Not fed to my baby
a. Fruit and vegetable juice?
b. Fruit?
c. Vegetables?
d. Meats, chicken and turkey?
e. Combination dinners (for example Spaghetti Dinner, Pasta and Vegetable Dinner, Turkey and Rice Dinner)?

23. During the past 7 days, were the baby foods your baby ate always, sometimes, rarely, or never organic baby foods?

Always

Sometimes

Rarely

Never

Don’t know

24. Which of the following supplements was your child given at least 3 days a week
during the past 2 weeks? (MARK ALL THAT APPLY)

F luoride

Iron

Vitamin D

Other vitamins or supplements:
Specify ________________________________

None

25. Were the supplements you gave your baby in the form of drops or pills?
[NOTE: MARK CRUSHED PILLS MIXED WITH LIQUID AS PILLS.]

Drops

Pills

26. Was your baby given and herbal or botanical preparations or any kind of tea or home remedy in the past 7 days? Do not count preparations put on the baby’s skin or anything the baby may have gotten from breast milk after you took an herbal or botanical preparation.

Yes GO TO QUESTION 27

No GO TO LAST PAGE

27. Please write in the name of all of the kinds of herbal or botanical preparations or teas your baby was given in the past 7 days.

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Thank you very much for completing this questionnaire!

All of your answers are very important.

Please help us by looking at each page again to make sure that you:

Did not skip any pages and

Crossed out the wrong answer and circled the right answer if you made any changes.

Thank you for continuing to be part of
the National Children’s Study.

1 Month IFQ - 11