What are some issues that parents face regarding breastfeeding versus formula feeding?

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 increasing energy balance secondary to caloric intake and
age-inappropriate dietary patterns [1, 5]. Children’s dietary behaviors are first formed during the critical ages of
birth to 2 years 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 dietary 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 professional agencies that provide child health information
sometimes promote conflicting early child feeding information and guidelines [19–21]. For instance, some agencies recommend the introduction of complementary
foods as soon as 4 months while others recommend
waiting until 6 months 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 growing 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 2 years old [24]. Healthcare,
community-based, and education providers can have significant 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 Declaration of Helsinki. Written informed consent was waived

with approval of the UConn IRB because interviews were
conducted by phone. Prior to the interview, each participant reviewed an information sheet and provided verbal
informed consent.
Participants
As part of a larger project by the research team to develop 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 expert 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 research team to determine interest in participating in the
study. Criteria for participants included being a healthcare 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 2 years 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 simultaneous 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 2 of 9

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 Interview Questions
To determine what feeding practices and obesogenic behaviors of
families with 0–2 year olds are observed by providers.
• 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?
To determine what barriers providers face when implementing early
childhood obesity prevention practices with families of young children.
• 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]?
To determine what nutrition education resource gaps providers identify
for use with families of 0–2 year olds.
• What other resources would be useful for you (as a provider or within
your organization) to further educate parents about feeding their child?