Australian research shows that parents frequently attend CFHN services for well-child checks. CFHNs are the preferred provider for advice on healthy diet and nutrition, breastfeeding support, sleep and settling issues, and information about play to support development [38]. This highlights their central public health role in promoting optimal infant growth and development, and their credibility with many parents.
This study examined the current child obesity prevention practices of CFHNs in two LHDs in Sydney, Australia, and the factors influencing them. Similar to a study in Melbourne [24], these CFHNs frequently undertake growth monitoring, use evidence-based resources, address infant feeding practices, and provide infant sleep and settling techniques important in obesity prevention. However, they less frequently use BMI or growth charts to identify children at risk of overweight and obesity or provide advice on correct formula preparation for parents using formula feeding.
Some findings on the frequency of specific activities in CFHNs’ practice may relate to the profile of children attending CFHN visits. The questions on the frequency of undertaking activities (Table 2) asked nurses to indicate them as a proportion of all consultations for children aged 0–5 years, not as a proportion of clients in a specific age range (i.e. 0–2 years and 2–5 years). Parents are less likely to visit CFHNs as their children grow older [38, 48] and some CFHN programs in the participating LHDs are specifically targeted to infants up to two years.
Subsequently, the lower reported frequency of growth monitoring for children aged over two years, or discussing options for active play and limited screen time for young children, may be explained by nurses who spend the majority of their time working with infants aged under two years. However, even if these practices are less frequent for children over two, these factors are potentially related to excess weight gain. It is therefore vital that CFHNs have appropriate education and resources to conduct them effectively whenever necessary.
Results indicated that frequency of height and weight measurement, then calculating and plotting BMI on charts for children aged 2–5 years, was lower than the equivalent monitoring on growth charts for infants aged 0–2 years. Nurse authors from the participating LHDs advised that BMI was automatically calculated and plotted after child height and weight was entered into electronic health record software. It is unclear why respondent-reported frequency of these activities undertaken in typical consultations with young children was low. Potential reasons may be that the primary reason for a consultation in infants, aged 0–2 years, is to monitor height and weight, whereas for children, aged 2–5 years, the primary reasons for consultation relate to development, behavioural issues, speech issues, and toilet training. Further, these consultations may take place outside a personal health record check, and if no parental concerns are voiced on height and weight, clinicians will focus on priorities parents articulate.
Responses indicate that the nurses are working with, at times, limited consultation time and health promotion resources to support families of young children and build strong relationships. Through their specialist CFHN education, they have an in-depth understanding of infant feeding and growth, enabling them to offer advice and support at most visits [49]. However, CFHNs identified key barriers to promoting healthy weight in infants and children that centred on parental behaviour and attitudes, including parents not recognising child overweight status, not being motivated to change lifestyle or diet, or not being concerned about child overweight if they are, themselves overweight. Interviews with CFHNs expanded on these topics and identified the importance of parental beliefs about healthy body size and weight, limited understanding on benefits of breastfeeding compared to formula feeding, and cultural perspectives on weight and feeding behaviour.
Findings on the cultural barriers to promotion of breastfeeding and healthy weight gain in children and infants are consistent with that in previous literature, including: pressure to fully or partially replace breastfeeding with infant formula [37, 50–54]; use of formula to encourage infant sleeping, feeding by other family members or reduce infant crying [36, 37, 50, 51, 55–58]; beliefs that large infants signified health, especially from countries where infants at are risk of malnutrition and undernutrition [36, 50, 52, 57–63]; limited access to support from nurses and midwives for infant feeding and care [54, 55, 64, 65]; and introduction of solid foods before 4–6 months [33, 56, 66], across South Asian, East Asian, Middle Eastern, African, Maori, Pacific Islander and Indigenous Australian populations and peoples migrating to overseas countries. Specific cultural beliefs were also identified, such as forceful infant feeding for weight gain by Bangladeshi parents, from fear that inadequate nutrition would result in child sickness or death [59, 67, 68], or norms where playing with children may not be common practice [69, 70].
CFHNs also reported lack of appropriate resources such as resources not tailored to cultural and religious groups [56, 71], and lack of services or resources in community languages or simple English [33, 61, 71, 72]. Selection and development of culturally appropriate resources may be difficult, as it requires use of appropriate language; targeting the client’s literacy level; specification to cultural and religious backgrounds and habits; and development with local community members [73]. Resources developed by Australian national and state government health bodies have been identified to contain culturally inappropriate information, such as multilingual translations containing unfamiliar or inappropriate concepts; unintended messages about cultural norms; lack of specificity for cultural practices [73].
CFHNs in this study reported high confidence in providing advice about introducing solid foods and healthy eating behaviours, although some were less confident in growth monitoring and identifying risk of overweight and obesity. However, previous research has shown that Australian parents require more education on evidence-based introduction of solids, to increase their understanding on infants’ readiness and to counter inaccurate guidance from family members or commercial baby food packaging [74]. Another study on Australian parents with children aged 2–5 years reported that CFHNs ‘brushed over’ their child’s weight issues and offered limited advice [75].
This research found that promoting healthy growth and avoiding rapid or excess weight gain can be challenging in families from cultural groups who may value formula feeding or large body size as symbols of health and status. Our findings identified not only parental negativity or defensiveness in discussing children’s weight, but also nurses’ own sense of discomfort. Growth and BMI charts are essential for CFHNs to calculate the risk of overweight or obesity, and to illustrate those risks to parents in a factual and non-stigmatising manner focused on health rather than fatness. Nurses identified that parental receptiveness to advice was frequently a barrier to promoting healthy weight gain.
Given that few nurses had formal recent training on behaviour change techniques (Table 4), nurses may benefit from additional training and support to engage parents from all cultural backgrounds, and to initiate ‘difficult’ conversations. Teaching nurses more about behavioural change techniques could assist them in advancing parents’ knowledge of strategies to maintain healthy weight among infants and young children, and equip them to support parental decisions and behaviour change.