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Image transcription text Content Points/Criteria Points/Criteria Points/Criteria Points Earned/ Comments Significance 1 Point 0.5 Point Poi… Show more Heller et al. BMC Public Health (2021) 21:1276 https://doi.org/10.1186/s12889-021-11305-7 RESEARCH Open Access A qualitative study of providers’ perceptions of parental feeding practices of infants and toddlers to prevent childhood obesity Rebecca L. Heller1,2, Jesse D. Chiero1, Nancy Trout3 and Amy R. Mobley4,5* Abstract Background: With a recent focus on establishing US Dietary Guidance for children ages 0 to 2 years old, the objective of this qualitative study was to determine misconceptions and barriers that prevent parents from implementing early childhood feeding and obesity prevention practices as reported by healthcare, community- based, and education providers. Methods: Trained researchers conducted one-on-one qualitative phone interviews, using a semi-structured script, with early childhood health and education providers working with families of young children. Interviews were audiotaped, transcribed verbatim, and analyzed using the classic analysis approach. Transcripts were coded by researchers and analyzed for themes. Results: Providers (n = 21) reported commonly observed obesogenic practices including overfeeding tendencies, early initiation of solids or less optimal feeding practices, lack of autonomy and self-regulation by child, and suboptimal dietary patterns. Sources of parental misconceptions about feeding were often related to cultural, familial, and media influences, or lack of knowledge about optimal feeding practices for infants or toddlers. Conclusions: Providers indicated a need for engaging and consistent child feeding and obesity prevention education materials appropriate for diverse cultural and literacy levels of parents, with detailed information on transitioning to solid foods. Early education and community-based providers reported limited access to evidence- based educational materials more so than healthcare providers. It is an opportune time to develop reputable and evidence-based child feeding guidance that is readily available and accessible for parents of infants and toddlers to prevent early childhood obesity. Keywords: Parental feeding, Childhood obesity, Healthcare provider, Infants * Correspondence: a..y@ufl.edu 4Department of Nutritional Sciences, Storrs, CT, USA 5Department of Health Education and Behavior, University of Florida, PO Box 118210, Gainesville, FL 32611-8210, USA Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Heller et al. BMC Public Health (2021) 21:1276 Page 2 of 9 Introduction Childhood obesity is a public health concern with both short- and long-term health consequences [1, 2]. Approximately one in every 10 children from age birth to 2 years old is at a high weight-for-length percentile [3, 4]. Overweight and obesity in childhood increases the risk of adult obesity and weight-related health conditions indicating a need for early behavioral interventions [1]. Rising childhood obesity rates have been linked to in- creasing energy balance secondary to caloric intake and age-inappropriate dietary patterns [1, 5]. Children’s diet- ary behaviors are first formed during the critical ages of birth to 2years when children are introduced to new foods and transition to an adult diet [6]. Early exposure to new and healthful foods, particularly through repeated exposure and feeding techniques, can help improve diet- ary behaviors [7-9]. Parents and caregivers serve as the primary direct influence on children’s intake through the types of foods they introduce and the methods they use to do so [9-11]. Specifically, parental feeding styles and practices have been associated with children’s dietary intake and weight status [12-14]. Previous studies have also identified healthcare and education providers as having significant influences on child feeding practices by way of parents and caregivers, with resulting positive and negative outcomes [15-18]. Essential resources for child feeding information are often disseminated by healthcare, community-based, and education providers to parents during the first few years of a child’s life. While health and education providers have an important role in educating parents about early childhood feeding and obesity prevention, several profes- sional agencies that provide child health information sometimes promote conflicting early child feeding infor- mation and guidelines [19-21]. For instance, some agen- cies recommend the introduction of complementary foods as soon as 4months while others recommend waiting until 6months of age. Further, some agencies recommend introducing cow’s milk before 12 months of age while others recommend waiting until at least 12 months of age. These conflicting messages may further contribute to inadequate or inappropriate feeding practices through increased confusion among parents and caregivers about proper timing and techniques to implement in early child feeding practices [22]. Despite the evident impact on dietary behaviors and health outcomes, there is limited research-based educational outreach currently targeting child-feeding practices for birth to 2-year-olds [22, 23]. To address the grow- ing issue of early childhood obesity, it is essential to provide parents and caregivers with evidence-based child feeding messages and to understand what obesogenic practices are being observed, their origin, and how providers address feeding issues. For the first time in history, the US Dietary Guidelines for Americans will include guidance on nutrition needs of children ages 0 to 2years old [24]. Healthcare, community-based, and education providers can have sig- nificant influences on parental child feeding practices [15, 16, 18, 25] and serve as key health communicators of timely and updated dietary guidance for infants and toddlers. The purpose of this qualitative study was to determine misconceptions and barriers that prevent parents from implementing early childhood feeding and obesity prevention practices as reported by healthcare, community-based, and education providers. Methods The study was approved by the University of Connecticut (UConn) Institutional Review Board (IRB) for Human Subjects, Human Research Protection Program, Protocol #H16-029 and conducted in accordance with the Declar- ation of Helsinki. Written informed consent was waived with approval of the UConn IRB because interviews were conducted by phone. Prior to the interview, each partici- pant reviewed an information sheet and provided verbal informed consent. Participants As part of a larger project by the research team to de- velop childhood obesity prevention messages for parents for future outreach, a convenience sample of participants were purposefully recruited from two US states where the lead researcher was located to include a variety of representative and experienced providers. An initial list of healthcare and education providers was developed with input from the project advisory committee and ex- pert input from the authors. Recommendations were based on types and specific providers who have a vested stake and expertise in childhood nutrition and/or obesity prevention. Providers were then contacted by the re- search team to determine interest in participating in the study. Criteria for participants included being a health- care or education provider known in the field with a minimum of 5 years work experience, at least 18 years of age, able to speak and read English, and working with families with children between birth to 2years of age. Participants were recruited in-person, via phone calls, or email. All participants contacted for an interview agreed. Interview To parallel with interviews with parents as part of a sim- ultaneous project [26], the interview questions for this study were based on personal beliefs and behaviors grounded in the Theory of Planned Behavior and the interpersonal factors and dynamic interactions of the Social Cognitive Theory [27]. Questions were reviewed by the study team and project advisory committee for Heller et al. BMC Public Health (2021) 21:1276 Page 3 of 9 face validity. A trained researcher conducted 60-min in- terviews with participants individually over the phone, and audio recorded with permission. Questions (Table 1) aimed to determine observed feeding and obesogenic be- haviors of families with young children, feeding, physical activity, and screen time, barriers faced in implementing obesity prevention practices, current resource gaps in nutrition education, and dissemination methods. Each provider received a small incentive valued at $10 for his or her time. Data analysis After the interviews were completed, the audio files were transcribed verbatim and verified by the researchers. Professional titles of providers were used to identify par- ticipants within transcripts. All interview questions ad- dressing the research objectives were included in data analysis (Table 1). Each transcript was analyzed using an open-coding in- ductive analysis process and analyzed for themes using the classic analysis approach and NVivo Pro 11 [28]. Thematic analysis was then used by a three-member study team to determine key emerging response themes for each question amongst the transcripts [29, 30]. Members of the study team included the lead author (RLH) who was involved in conducting interviews and able to confirm study findings along with two other study authors (ARM, NT) who were not directly in- volved in conducting interviews but who were able to provide objective analysis to reduce any potential bias. Question response themes were coded and summarized for frequency among interviews by each individual team member independently. Once all transcripts were analyzed by each team member, the study team convened to dis- cuss common findings and confer major response themes. Multiple reviews were used at each stage of qualitative analysis to increase validity of the findings [31]. Results The final sample for this study consisted of 21 providers, including early education providers (n = 7), community- based providers (n = 7), and healthcare providers (n = 7). The final sample size was determined once representa- tives from a variety of professions and roles within the community were included and data saturation was reached based on no further new information provided during the interviews. Emerging themes were summarized for observed feeding practices, barriers to childhood obesity prevention, and nutrition education resource gaps (Table 2). Observed feeding practices Overfeeding as it relates to improper portion sizes was one theme that emerged as an observed feeding practice in families with young children. One provider stated, “They overfeed their kids. They’re not aware of just how small the portion sizes are for kids especially zero to two, ” (Lactation Consultant). A community education ob- served that, “Sometimes families think they should be get- ting a lot more than they actually need, so we actually have a large amount of kids that are actually on the higher end of weight,” (Early Head Start Education Man- ager). Providers also reported that families are concerned about their child not receiving enough food, especially during birth to 2 years when their diet is transitioning. One provider explained, “[…] most commonly, I see over- feeding and parental anxiety about underfeeding. Even though most children are overfed, most parents are wor- ried that they’re underfed,” (Pediatrician 1). Another pro- vider (Pediatrician 3) indicated that while some parents struggle to have the means to provide enough food, others use food to soothe their child. Parents may ex- perience anxiety and seek other sources to add calories and nutrition into their child’s diet as indicated by a WIC Nutrition Director, “When the children turn a year Table 1 Interview questions with providers to determine perceived practices, barriers and educational opportunities to prevent early childhood obesity of children ages birth to 2 years old Research Objective To determine what feeding practices and obesogenic behaviors of families with 0-2 year olds are observed by providers. To determine what barriers providers face when implementing early childhood obesity prevention practices with families of young children. To determine what nutrition education resource gaps providers identify for use with families of 0-2 year olds. Interview Questions • What are some issues that parents face regarding breastfeeding versus formula feeding? • What are some issues parents face with complementary foods? • What foods or food related practices do parents have the most trouble implementing? • What are some common misconceptions/confusion that parents have regarding feeding their baby/child? • If parents have mentioned misconceptions these to you, where do these misconceptions tend to come from? • What are the most common reasons why parents do not or are unable to follow the feeding advice or suggestions given? • What reasons do they give for not following it [suggestions for food/ drinks parents should avoid giving their children]? • What other resources would be useful for you (as a provider or within your organization) to further educate parents about feeding their child? Heller et al. BMC Public Health (2021) 21:1276 Page 4 of 9 Table 2 Emerging qualitative research themes identified by providers regarding observed feeding practices of parents, barriers and educational opportunities for early childhood obesity prevention Research Topic Observed Feeding Practices Barriers to Childhood Obesity Prevention Nutrition Education Resource Gaps Emerging Themes • Overfeeding in absence of hunger • Early initiation of solids & suboptimal feeding practices • Lack of child autonomy & self-regulation • Suboptimal dietary pattern (Limited vegetable intake, excess high energy-dense food intake) • Convenience (time and energy for busy parents) • Marketing from social media & food companies • Cultural & familial influences • Lack of knowledge & misconception about healthy foods • Reputable, evidence-based & accessible information • Culturally/literacy sensitive materials & engaging for parents • Limited resources on transitioning to solid foods (month-specific) old, there’s a significant number of parents […] who are anxious about their child eating well, transitioning off of formula onto food, and so they want a supplemental beverage.” Early initiation of solids and inappropriate techniques transitioning to solid food was also an emerging theme. One provider explained “[…] there’s a misconception about when to give the solid foods or try them. I think a lot of them [parents] are doing it sooner then it’s really recommended.” “[…] some of the older [health profes- sionals] are the ones that are encouraging them to start solids sooner than recommendation of around six months.” (Lactation Consultant). This early initiation was observed as a disregard for current recommenda- tions and was further described as part of a larger phenomenon. One provider explained that parents were “[…] giving cereal at an earlier age than we recommend because they don’t understand the anatomical needs for the baby to be able to take it safely.” (Pediatric APRN). This observation included not only a general lack of un- derstanding by parents about when to initiate foods for their infant, but a desire to include the child in family meals. Another provider reported “[…] they like to try and feed their kids earlier than we would even recom- mend and not wait – you know how you’re supposed to wait like three days for every food introduced, so that way you see if there’s allergies.” This became an issue as the provider further explained instances where “you might have to stop all foods right now, because there’s something going on and because we’ve introduced so many things, we don’t know what it is,” (Early Head Start Education Director). Another inappropriate technique observed related to early initiation of solid food was introducing solid foods in a baby bottle. One provider described this practice by quoting a parent’s statement of, “Well, this is what my mom told me to do.’ Cereal in the bottle and the intention really is to make sure they sleep through the night.” (Lactation Consultant). Another healthcare provider (Pediatrician 3) indicated that col- leagues have sometimes suggested adding foods such as cereal to a bottle when a child is struggling to gain weight although it is not recommended practice. Another feeding practice observed by providers, espe- cially childcare directors, was the lack of autonomy and self-regulation for children ages birth to 2 years during mealtimes. One provider reported that “[…] one of the biggest challenges is parents are afraid to start little pieces of solid food because they’re afraid their children are going to choke and so we have a lot of challenges with encouraging families to start finger foods,” (Childcare Director 1). Another provider explained lack of auton- omy during mealtime as “[…] it’s the parent’s worry of choking… and helping the parents to distinguish the difference between the child feeling out a new texture in their mouth and the child actually choking,” (Childcare Director 3). The lack of autonomy and self-regulation was also seen with children who were simply not accustomed to feeding themselves. Self-regulation, as it relates to child feeding, is a child’s ability to start and stop eating in re- sponse to hunger and fullness cues respectively. A pro- vider explained that “The parents are always feeding them or they – and so you get these kids coming to us maybe even as toddlers who will have a plate full of food in front of them and they won’t pick it up and put it in their mouth themselves even though physically they’re able to pick up food and put it in their mouth,” (Child- care Director 1). Another provider indicated, “The chil- dren are not using cups and forks or spoons when they should be. We try to help them transition but it’s not happening at home.” (Childcare Center Teacher 1) Not only were parents feeding their child, but they also opted to feed their child over letting their child attempt self- feeding. One provider stated, “So that’s one hard thing for some parents, because it’s easier, quicker, sometimes less messy to feed them themselves, rather than have the child feed themselves,” (Childcare Director 2). Another source of this feeding behavior was the fear of messy eating. A provider gave details on the response to one parent’s concern, “The other thing is […], they’re going to Heller et al. BMC Public Health (2021) 21:1276 Page 5 of 9 make a mess.” (Childcare Director 1). Concerns of a child making a mess also extended to feeding practices for toddlers at childcare centers where family style serving options were not implemented. (Childcare Cen- ter Teacher 2). The final emerging theme was that of suboptimal dietary patterns during the transition to solid foods. Providers observed that children have too little produce, particularly vegetables, in their diet, and excess high energy-dense foods and added sugars. Some providers (Pediatrician 4 and Registered Dietitian 2) indicated a re- duction in diet quality once a child turned 1 year of age or began eating table foods with their family. When asked about foods lacking in the diet during this time, providers clearly stated “Vegetables. [Their] vegetables and – yeah, vegetables, it’s mostly the children – espe- cially the green vegetables.” (Community Educator). Although fruit was another concern, providers men- tioned that it was variety that was lacking. One provider explained that it was often a financial barrier in regard to increasing fruit variety in the diet. This provider said “[…] if they buy bananas, they cannot buy apples. If they have the banana and apples, they cannot have the peaches and the plums […]” (HHC Community Health Educator). This lack of produce in the diet was not an isolated issue. A provider elaborated by saying, “In general, […] they don’t have much in the way of fruits and vegetables. They eat excessive amounts of refined carbohydrates and foods that have added sugar […],” (Pediatrician 2). Some specific examples included “Lots and lots of juice. And drinks that they perceive as juice like Kool-Aid, lemon- ade, iced tea. […] They give too much junk food, take-out food, chicken fingers, macaroni and cheese, crackers,” (Pediatric APRN). There was further concern on sugar- sweetened products such as “Juice for sure. And sweet stuff. Not enough fruit, but getting their sweet stuff from other candy or cookies.” (Early Head Start Home Visitor). Another observation by providers was related to foods marketed to parents for children. A provider explained that “I think parents feel that they need to give their chil- dren special foods, baby foods, foods marketed to toddlers […],” (Pediatric RD 1). Barriers to following childhood obesity prevention recommendations Convenience, such as time and energy needed to prepare food, appeared as one thematic barrier for parents to fol- low childhood obesity prevention recommendations. One provider explained that some parents do not follow recommendations because “In the morning sometimes is hard because they’ll do a run to [a fast food donut shop] and then – or they’ll grab something quick […],” (Child- care Director 2). Besides saving on time, convenience also meant easier choices. Another provider described how parents make less optimal feeding choices simply to avoid conflict, stating, “I think it’s just easier. They say like their kids are crying and they want it, so they just give it to them,” (Early Head Start Education Manager). Providers also reported concern that the desire for con- venient options led to relying on supplemental products, “I felt like the whole reason for the toddler formula was just because again it was easier and it was putting this parent’s mind at ease […],” (Childcare Director 1). Another observed barrier was the marketing of less healthy or unnecessary foods for young children by so- cial media and food companies. One provider described this occurrence, saying, “Well, maybe it’s what they’re watching on TV or the advertising on TV.” (Lactation Consultant). This marketing presence had a clear impact on what parents provide for their children. Another pro- vider observed that “They want to give [liquid nutrition supplement], or they want to give toddler formula, be- cause advertising is out here,” (WIC Nutrition Director). The marketing not only influenced parents’ decisions, but created confusion. When asked where misconcep- tions on child feeding came from, a provider stated “I think the media is one thing and family and friends. […] and of course now with the internet and chat rooms and all of this, it’s a lot of electronic information,” (WIC Nu- trition Director). Cultural and familial related influences were another potential barrier to childhood obesity prevention and were a constant obstacle that many providers observed when working with parents. One provider cited an ex- ample related to mealtime barriers “[…] I think that there’s a lot of family input, extended family input so that can be a very hard barrier to break, those cultural norms,” (Pediatric RD 1). One specific example of cul- tural influences from the family was that “if there is an older family member, like, a grandmother who for cul- tural reasons believes otherwise and […], this last year I had somebody from India, and she said in India they have a special ritual at five months old with the intro- duction of baby food. And that is their cultural norm and so I just said well, this is what we advise in the United States based upon the AAP recommendation,” (WIC Nutrition Director). Another example was pro- vided when the provider further stated, “I think they just go on to the internet or talk with family and friends, and we do have a large Latino population […], and so the Latino culture has some beliefs, early introduction of baby food, putting cereal in the bottle has been one of them,” (WIC Nutrition Director). All of these barriers were further exacerbated by the final emerging theme of the lack of knowledge and misconceptions of healthy foods. Providers believed that parents are genuinely concerned about their child receiving Heller et al. BMC Public Health (2021) 21:1276 Page 6 of 9 proper nutrition, but that parents do not understand what that entails exactly. One provider explained, “Most people are interested in nutrition. They want to feed their kids healthy foods. They just don’t necessarily know what is healthy and/or unhealthy,” (Pediatrician 1). On a simpler level, providers observed that some parents see all food as adequate sources of nourishment. This provider elaborated “[…] for many parents, in a sense, all food is good including commercial food. And so there’s a trust in that and I think sometimes that trust is violated commercially,” (Pediatrician 2). Even for parents who may be able to differentiate be- tween healthy and unhealthy foods, providers reported there are still misconceptions preventing parents from making healthier choices. The most common of these being that all healthy foods are too expensive to include in their diets. One provider expressed how frequently this issue came up by explaining, “We hear a lot that it’s expensive. It’s all on the outside of the store we all know. It’s easier to buy a box of hamburger helper. So, there’s a misconception too, eating healthy doesn’t have to cost you a lot of money,” (Lactation Consultant). Nutrition education resource gaps Community-based and early education providers reported many resource gaps that prevent optimal nutrition educa- tion. One main concern was the lack of reputable, evidence-based materials that are accessible to the providers and parents they work with. One provider con- firmed, “I think it would be great for us to have a suggested list of websites that would be considered really valid, ap- proved resources, recommended resources […]” (Childcare Director 1). Many providers, particularly those working in community-based areas, expressed concerns with acces- sing these resources, “If I think it’s a good resource, I find it online and I think it’s a good resource, I’ll give it out. [..] Some of the stuff I really have to put together because I weed through it.” (Early Head Start Home Visitor). In addition to reliable materials, community-based and early education providers were also lacking access to nu- trition education resources that were sensitive to cultural and literacy differences, and engaging for parents. Providers reported serving families from a variety of cultural backgrounds, and this affected their diet and ability to understand educational materials. One pro- vider explained the challenge “It’s always been – espe- cially because of the language. We don’t have anything in Spanish, so we have to – I have to do a lot of transla- tion.” (Community Educator). There was also a lack of nutrition education resources available for low-literacy parents. A provider reported that “They do have some stuff that we can get out to families, but it’s a lot of read- ing and the demographic that we serve is lower income and a lot of our families can’t even read past eighth grade level,” (Early Head Start Education Manager). Further, another provider indicated, “Parents often lose handouts and it would be good to have something with good photos to show them online or their phone that they can read when they need it.” (Childcare Center Teacher 2). Aside from these cultural and literacy needs, health- care providers identified a lack of engaging resources that can be used with all parents. They also observed that parents did not learn best with current formats of nutrition education materials. Providers explained that parents needed more visual-based resources to capture their attention and help them understand the informa- tion: “I think that what would be most helpful for parents is things that are very visual. So I think we have a lot of information that’s written and I think that’s great, but a lot of the time parents aren’t interested in reading hand- outs or they’re just not that type of learner and so seeing something that’s even more hands-on or a video or some- thing that’s very visual for them is gonna [sic] be more beneficial,” (Pediatric RD 1). Another provider indicated, “An app for their [mobile] phone would be a good way for them [parents] to have information at their finger- tips.” (Pediatrician 3). In terms of specific topics that were lacking in current nutrition education materials, providers reported that parents needed more information about transitioning in- fants to solid foods. One provider explained, “So I think there’s lack of education in that area […] transfer from breastfeeding to regular, table food.” (Community Educa- tor). Another provider insisted, “I would love to have feeding for the babies on a monthly basis, […], and up to five years old,” (HHC Community Health Educator). A provider explained that “[…] from infant to 2 years old, I also believe that we also need more educational mate- rials […] I have to do a lot of cut and paste because we don’t have a lot of resources.” (Community Educator). Discussion The findings from this qualitative study identified a pro- vider perspective on early child feeding practices of parents and current education gaps. Overarching themes were cate- gorized as observed feeding practices, barriers to childhood obesity prevention, and nutrition education resource gaps. Within observed feeding practices, providers reported parental overfeeding of young children due to a lack of knowledge and misconception of healthy portion sizes and nutritional requirements for young children. The overall findings of providers’ perceptions intersect and parallel actual concerns and needs of parents as reported in prior research [26]. Previous studies found that mothers from diverse populations primarily associated crying and distress with hunger [32, 33] and the belief that infants should finish the entire bottle at feeding times, increasing obesity risk [32-34]. Parents also often serve inappropriate portions linked to increased energy intake [35, 36]. Heller et al. BMC Public Health (2021) 21:1276 Page 7 of 9 Early introduction of solid foods by parents was also of concern to providers as it relates to observed feeding practices and was associated with a lack of knowledge and cultural or familial influences. Although some research indicates that parents are aware of the import- ance to delay solid foods [37], previous research found that early introduction of complementary foods was associated with diets high in energy dense snacks and sweets and lower in fruits and vegetables [38, 39]. Additional studies have shown that early introduction of solid foods was positively

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