Sample
Ninety nurses completed surveys, representing a 58% response rate of CFHNs across both LHDs. All respondents were female, with half (51%) aged 50 years or above. In terms of experience, 19% had worked as CFHNs for less than five years, while 52% had over 10 years’ experience (data not presented) (Additional File 3). Interviews ceased at twenty as no new themes were emerging and we considered that data saturation was achieved. Interview times ranged from 30 minutes to 1 hour. We did not report demographic data on the twenty interviewees to preserve confidentiality.
Survey findings
Survey respondents reported a varying caseload, ranging from one to over 30 consultations weekly, with a mode of 10-19 consultations. Three-quarters of responses reported that routine clinical assessments for infants and children up to five years accounted for the majority (≥51%) of consultations; other key reasons were breastfeeding support and education on other infant feeding issues (Table 1).
Table 1. Proportion of nurse consultations with infants and young children, aged 0-5 years.
Consultation reason
|
No. of responses
|
Proportion of all consultations - n (%)
|
None
|
Few
(1-25%)
|
Some
(26-50%)
|
Majority
(≥51%)
|
Routine baby or child health checks
|
89
|
2 (2.2)
|
6 (6.7)
|
14 (15.7)
|
67 (75.3)
|
Breastfeeding advice or support
|
86
|
0
|
18 (20.9)
|
43 (50.0)
|
25 (29.0)
|
Other infant feeding advice or support (excluding breastfeeding)
|
85
|
0
|
21 (24.7)
|
41 (48.2)
|
23 (27.1)
|
Immunisations
|
80
|
70 (87.5)
|
3 (3.8)
|
1 (1.3)
|
6 (7.6)
|
Acute health problem
|
81
|
33 (40.7)
|
41 (50.6)
|
7 (8.6)
|
0
|
Chronic health problem
|
83
|
33 (37.5)
|
46 (57.5)
|
4 (5.0)
|
0
|
Most respondents (≥90%) had easy access to growth and body mass index (BMI) charts, and educational materials on infant feeding, infant sleep and settling, and healthy eating for pre-schoolers and toddlers. Fewer respondents could easily access education materials on promoting active play (86%) and limiting sedentary behaviours (61%) (data not presented) (Additional File 3).
Most respondents agreed that providing advice on infant feeding (100%) and healthy lifestyle behaviours for the whole family (95%) was central to their role. Many believed that their advice and support promoted the adoption of healthy lifestyle for the whole family (75%) and most found it professionally rewarding to address healthy lifestyle behaviours with families of young children (94%) (data not presented) (Additional File 3).
Table 2 indicates how often CFHNs addressed specific issues related to healthy weight gain.
Table 2. Frequency of activities provided in typical consultations with young children, aged 0-5 years.
|
No. of responses
|
Proportion of consultations, n (%)
|
Never to sometimes (≤50%)
|
Often to mostly
(≥51% )
|
Feeding advice and support
|
Encouraging continuation of breastfeeding in breastfeeding mothers
|
87
|
12 (13.8)
|
75 (86.2)
|
Offering water as the main drink for children ≥12 months
|
87
|
12 (13.8)
|
75 (86.2)
|
When to introduce solids to infants
|
87
|
14 (16.1)
|
73 (83.9)
|
How to introduce solids to infants
|
87
|
13 (14.9)
|
74 (85.1)
|
Parents eating meals with their children
|
87
|
14 (16.1)
|
73 (83.9)
|
Limiting intake of sweetened drinks
|
87
|
12 (13.8)
|
75 (86.2)
|
Increasing fruit and vegetable intake
|
87
|
27 (31.0)
|
60 (69.0)
|
Limiting high sugar and/or high fat foods
|
86
|
28 (32.6)
|
58 (67.4)
|
Provide correct formula preparation advice to parents who are formula feeding their infants
|
87
|
47 (54.0)
|
40 (46.0)
|
Behaviour advice and support
|
Sleep and settling techniques for infants
|
88
|
13 (14.8)
|
75 (85.2)
|
Limiting TV or other screen-based activities
|
88
|
30 (34.1)
|
58 (65.9)
|
Limiting TV and electronic media use to ≤1 hour/daily for children aged 2-5 years
|
86
|
33 (38.4)
|
53 (61.6)
|
Increasing active play for young children
|
87
|
36 (41.4)
|
51 (58.6)
|
Growth charts and measurements
|
Measure height and weight of children aged ≤2 years
|
87
|
7 (8.0)
|
80 (92.0)
|
Plot height and weight of children aged ≤2 years on growth chart
|
87
|
9 (10.3)
|
78 (89.7)
|
Use growth or BMI chart to identify infant or child at risk of overweight or obesity
|
84
|
37 (44.0)
|
47 (56.0)
|
Measure height and weight of children aged ≥2 years
|
87
|
40 (46.0)
|
47 (54.0)
|
Calculate BMI of children aged ≥2 years and plot on BMI percentile chart
|
85
|
49 (57.6)
|
36 (42.4)
|
Referral to other services
|
Referral to an allied health professional
|
33a
|
22 (66.6)
|
11 (33.3)
|
Referral to dietitian
|
87
|
75 (86.2)
|
12 (13.8)
|
Referral to weight management clinic
|
87
|
80 (92.0)
|
7 (8.0)
|
BMI: body mass index
a Some respondents using the paper survey did not indicate how often they referred to allied health professionals. 51 respondents reported referring to allied health, with the most common referral being to dietitians (24), speech pathologists (20), physiotherapists (15), and occupational therapists (14), as well as feeding clinics, dental services, psychologists and lactation consultants .
The issues ‘often’ or ‘mostly’ addressed by CFHNs with parents in a typical consultation pertained to breastfeeding, food and fluid intake, eating habits, sleep techniques and limiting screen time (Table 2).
The questions did not explore what CFHNs did in consultations after they calculated a child’s body mass index, although Table 2 indicates that small proportions regularly make referrals to other health services including dietitians and or weight management clinics. While CFHNs frequently measured height and weight, which is plotted on growth charts for children aged less than two years old (92% and 90% respectively), these activities were less frequent for children aged between 2-5 years (54% and 42% respectively). Just over half of the survey respondents (56%) ‘often’ or ‘mostly’ used growth or BMI charts to identify infants or young children at risk of overweight and obesity, regardless of the age of the child.
Respondents were less likely to address some aspects of nutrition: only two-thirds ‘often’ or ‘mostly’ discussed increasing fruit and vegetable consumption or limiting foods high in fats or sugar. They also advised parents on physical activity less often. It is important to note that less than half the respondents reported that they ‘often’ or ‘mostly’ advised parents on best-practice formula preparation.
Most survey respondents reported higher confidence in these activities (data not reported) (Additional File 3). Some respondents reported lower confidence in calculating the BMI of children aged 2-5 years and plotting this on a BMI percentile chart (13%), and identifying infants and young children at risk of overweight and obesity (16%).
The health professional guidelines used most commonly by respondents were the national infant feeding (93%) and healthy eating guidelines (84%), with physical activity (64%) and sedentary guidelines (51%) used less often. Other resources used by nurses included websites and brochures from health professional industry organisations [42-44] and state government bodies [45-47].
Barriers to parental uptake of lifestyle advice for infants and children
Survey respondents identified barriers that could reduce parental uptake of lifestyle advice for infants and children, rated as moderately or very important (Table 3). Over half the respondents identified the following barriers: lack of recognition that child is overweight; lack of motivation to make lifestyle changes; lack of concern or action about child’s weight; lack of priority attached to child’s weight; and concerns that parents will not find the advice relevant or effective. The impact of socio-economic factors such as the cost of healthy food on infant and child feeding decisions was also an important barrier. Over 60% of respondents also considered that limited clinical services or insufficient time for health promotion were important structural barriers.
Table 3. Key barriers affecting promotion of healthy weight gain in infants and young childrena.
Barrier
|
N
|
n (%) responses rating the barrier as importantb
|
Moderately important
|
Very important
|
Total
|
Parent doesn’t recognise child is overweight
|
86
|
30 (34.9)
|
54 (62.8)
|
84 (97.7)
|
Parent not motivated to change diet or lifestyle
|
86
|
19 (22.1)
|
61 (70.9)
|
80 (93.0)
|
Parent is overweight, so unconcerned that child is overweight
|
84
|
30 (35.7)
|
47 (56.0)
|
77 (91.7)
|
Socio-economic factors (e.g. cost of healthy food)
|
86
|
32 (37.2)
|
46 (53.5)
|
78 (90.7)
|
Child’s weight not a parental priority
|
87
|
39 (44.8)
|
29 (33.3)
|
68 (78.2)
|
Advice is not effective
|
84
|
25 (29.8)
|
34 (40.5)
|
59 (70.2)
|
Nurse’s concern that parents will not be receptive to advice
|
86
|
31 (36.0)
|
27 (31.4)
|
58 (67.4)
|
Advice irrelevant to presenting issue
|
85
|
30 (35.3)
|
26 (30.6)
|
56 (65.9)
|
Lack of clinical services for additional/ongoing parental support
|
85
|
28 (32.9)
|
26 (30.6)
|
54 (63.5)
|
Nurse’s lack of time
|
83
|
33 (39.8)
|
18 (21.7)
|
51 (61.5)
|
Nurse’s concern that parents will not act on advice
|
85
|
25 (29.4)
|
26 (30.6)
|
51 (60.0)
|
a See Additional File 1 for all questions.
b Remaining respondents rated the barrier as ‘not important’ or ‘slightly important’.
Perceptions on healthy weight gain promotion for infants and young children
In addition to questions on barriers to promotion of healthy weight gain, respondents described their perceptions on their role in advising parents on healthy lifestyle behaviours (data not reported) (Additional File 3).
Many CFHNs (66%) agreed that some parents reacted negatively to discussion of child’s weight. Almost half (49%) felt they did not have sufficient time to properly address healthy lifestyle behaviours with families with young children. Just over a third (35%) felt uncomfortable raising the issue of infants’ and young children’s weight with parents. Few (18%) agreed that they had clients who were generally not interested in development of healthy lifestyle habits for their children.
Addressing barriers through nurse education
Table 4 shows the areas in which respondents had received formal training (i.e. more than one hour of professional designed instruction) in the past two years. Over half of respondents received instruction about breastfeeding, introduction of solids for infants, healthy eating and active play. Less than half received instruction about obesity prevention, obesity management, or behavioural change techniques.
Table 4. Nurse participation rates in education in past two years (N = 90).
Education topic
|
n (%)
|
Breastfeeding
|
80 (88.9)
|
Introduction of solids to infants (e.g. timing, types of foods)
|
60 (66.7)
|
Healthy eating for young children (0-5 years)
|
57 (63.3)
|
Healthy infant feeding practices (e.g. eating together as a family, use of food as reward)
|
55 (61.1)
|
Active play for young children (0-5 years)
|
42 (46.7)
|
Obesity prevention in children
|
41 (45.6)
|
Limiting sedentary behaviour (e.g. TV watching) in young children (0-5 years)
|
38 (42.2)
|
Obesity management in children
|
31 (34.4)
|
Behaviour change techniques
|
28 (31.1)
|
Formula feeding education was not addressed in the survey.
Most respondents (68, 76%) were interested in additional training in promoting healthy weight gain in young children. Respondents preferred training workshops (59%) or learning through online self-study material (39%).
Interview findings
CFHN perceptions of parental views about healthy weight in infants and children
Interview data confirmed and elaborated survey findings about barriers to parental uptake of healthy weight and feeding advice from CFHNs. Qualitative analysis indicates that nurses perceived that the barriers encountered related to parents’ beliefs about health, wellness, the benefits of breastfeeding and formula use, and the use of feeding to settle infant behaviour. CFHNs also highlighted factors, such as obsolete and inaccurate practices, and cultural feeding conventions, conflicting with Australian health care advice. Interviewees recounted that parents may believe that an overweight child is a ‘normal’ size; is a familial norm; or is indicative of health or wealth. Parental beliefs about the advantages of formula feeding compared to breast feeding also challenged CFHNs’ capacity to influence their child feeding practices. Nurses suggested that these beliefs were sometimes strongly influenced or endorsed by relatives and friends. In cases where parents were open to making lifestyle changes, their intentions could be challenged or even opposed by significant relatives or friends.
‘Large is healthy’, ‘normal’ or a familial norm
Interviewees explained that some parents’ beliefs or norms about infant body size resulted in a difficulty recognising weight problems in their own children, even when presented with clinical evidence.
“So, there are ideas around some of the cultures that we work with… that a fat, large baby is a healthy baby… when they actually look at a[n overweight] child, they’ll look at them and go, ‘but they’re normal.’ Because they’ve actually changed the way they look at them. And when you show them what a normal child looks like, they'll argue with you that they're unhealthy.”
(Interviewee #15)
In the experience of CFHNs, large body size was perceived by some cultures as reflecting good health and wealth status, and tended to be highly sought by some people from culturally and linguistically diverse (CALD) groups.
“[For] the Chinese, Indian, Vietnamese, Nepalese… because they've come probably from very poor circumstances… it's still a symbol of wealth – fat, healthy children. But they don't necessarily want them to be fat… it’s that wealth thing, that rich people use formula, rich people do this. And here they can do it [use infant formula]… [they see] that we’re giving our baby bottles.”
(Interviewee #8)
CFHNs reported that some parents, who they described as overweight themselves, considered this as their family norm. CFHNs indicated that these parents were not concerned about the issue of child overweight and were less amenable to modify health behaviours.
“[They say] ‘Oh, we're all big in our family. It's good to be a big healthy, you know, baby.’”
(Interviewee #2)
“When I’ve had [paediatric patients] where they're overweight, and I really do want them to go and see a dietitian, or talk about it, the parents would say, ‘well, you know, there's nothing wrong with me, you know, and I'm big’, or one I can remember, they owned a pastry shop, and just said, ‘that's just how we live’.”
(Interviewee #16)
CFHN perceptions of parental beliefs about nutrition and activity
Breastfeeding and formula feeding
CFHNs indicated that some parents expected breastfeeding to be a pain-free, easily mastered skill. When breastfeeding experiences were contrary to their expectations, or they perceived their milk supply to be insufficient, parents opted for formula feeding instead.
“When [breastfeeding’s] not [great], they’re very disillusioned… formula is just so easy for people to get… they’ll go, ‘Oh, I’ll just give my baby some formula, he’ll start sleeping,’ or… ‘You won’t have to feed every two to three hours’, without knowing exactly what it is that formula does to the baby…
… they haven't been [breast]feeding well from the start… so ‘I'll offer this bottle, oh, wow, look at that, my baby is now sleeping.’ And then, you just start into that cascade until the formula just becomes the normal.”
(Interviewee #2)
CFHNs reported parental beliefs that formula feeding is nutritionally equivalent to breastfeeding. These beliefs were fostered by family and social influences, which could also over-rule parents’ own breastfeeding intentions.
“The misunderstanding in some cultures that formula fed babies are just as well catered for with formula feeding, and that formula feeding is the same as breastfeeding, which is not true.”
(Interviewee #20)
Responding to infants’ cues
CFHNs reported parents using formula feeding or early introduction of solid foods to manage fussy eating, sleep and settling issues.
“[Parents] think that [infants] should just be all calm and settled all the time. … So, looking at things like… baby cues, and whether they’re hungry, whether they’re tired… because a lot of them misrepresent it and they tend to [think] ‘Oh, I’ll just feed them anyways’.”
(Interviewee #15)
“… someone has said to them, ‘Oh no, you know, if they’re not sleeping well’, or something like that, ‘oh, you need to start solids.’… But there’s always someone telling them if they’re having difficulties, ‘oh, look, you can just put the baby on the bottle.’”
(Interviewee #1)
Family influences
Family members, especially grandparents, are often in a powerful position, directly or indirectly, to influence parents’ infant feeding practices. Difficulties arose when older, influential people promulgate outdated information, culturally traditional feeding advice, or preference for formula feeding to breastfeeding that conflicted with the evidence-based advice provided by CFHNs.
“So you might have a mum who’s doing really well, exclusively breastfeeding. She goes home to country and she comes back and she’s giving them a bit of both [breastfeeding and formula feeding], ‘cause that’s what [her] mum did… even though you’ve put [exclusive breastfeeding] into motion, shared it, talked to them about it, family has a really big impact on their decisions that they make.”
(Interviewee #5)
“We have a lot of Bangladeshi families coming through, and they seem to do a lot of force feeding, or hand feeding the child, and that’s a very cultural thing. So… we do a lot of talk around letting the child feed themselves, sitting with the family and eating as the family. It seems to be this thing of, you know, just trying to get the food in the child, and as much as you can, of it. … Dealing with their cultural beliefs about eating.”
(Interviewee #4)
“I think the more vulnerable people are… not as receptive and they tend to follow their families… I do see quite a few Aboriginal families, and they would tend to just follow… what's been done previously… feeding the wrong foods at the wrong times and giving too much from a bottle…”
(Interviewee #14)
Infant physical activity and play
Interviewees identified other cultural norms that prevented parental uptake of CFHNs’ advice on healthy eating and physical activity.
“Well, we talk to them about not using walkers at all. Unfortunately in the Bengali culture, having a walker is being seen as wealthy. We talk about walkers as being unsafe and the fact that they actually inhibit their gross motor development rather than enhance it. … They pass them on to each other because they're seen as a sign of wealth.”
(Interviewee #15)
“I’ve revisited families and I find the more I can role model it—so if I’m talking about tummy time, if I actually show them tummy time… you can talk to it ‘til you’re blue in the face, but… in a lot of cultural situations, they don’t put their babies down on the floor.”
(Interviewee #4)
Additional resources
Some CFHNs felt that limited clinical time and resources impeded their ability to advise parents effectively:
“I don't know whether they necessarily have enough contact with us to appreciate sometimes what we're trying to say. I don't know whether we're making any great changes or having any great influence on their decisions… Probably because the amount of time that we get to spend with people.”
(Interviewee #3)
Professional education can maintain and refresh CFHNs’ knowledge of evidenced-based practice. Almost half the interviewees reported having sufficient confidence in their practice and needed no further resources to help address healthy weight gain. Others, although confident, were interested in attending more education sessions out of professional interest.
“I've been doing this for a long time, so I just like to do ongoing education, keep up to date with the latest guidelines, with education on difficult things, you know, certain allergies and stuff like that.”
(Interviewee #8)
CFHNs who wanted to improve their confidence suggested additional topics of interest, including using behaviour change communication and techniques for parent education; motivational interviewing; anticipatory guidance and counselling to address parental resistance to change and sensitivity regarding child weight; feeding, eating and activity strategies, such as management of feeding difficulties, fussy eating, food refusal, bottle cessation, weaning from breastfeeding; and addressing cultural practices, beliefs and norms of CALD groups in the client population, particularly East Asian, South Asian, Arabic and Australian Aboriginal and Torres Strait Islander groups.
Clinical resources for parents
Nurses discussed the need for resources for parents and caregivers to supplement nurse education to parents. Topics included evidence-based information and resources explaining consequences of early screen exposure for infants; benefits of active play and activity; consequences of rapid weight gain, overweight and obesity on infant and child health outcomes; and health effects of breastfeeding compared to formula feeding.
“… in terms of infant feeding, maybe [demonstrating] the effects of introducing formula to babies, so that people are aware that, ‘okay, yes, it’s an infant food, but it should only be used if there’s no other option’ … what effect it is going to have on the baby…”
(Interviewee #2)
“We quite often get the question… how much TV should they watch or how much screen time should they have? … and really, the only information that we have to tell them is that the less, the better.”
(Interview #13)
CFHNs suggested video resources, focused on infant food preparation and storage; positive examples of parent-child interactions for feeding, self-feeding and baby-led weaning; and examples of movement, play and physical activities for infants.
“I would love to have some videos of… happy baby eating, feeding, playing with their food… compared to the force-fed baby…”
(Interviewee #6)
They identified the need for cultural-specific resources for parents, featuring cultural foods, multilingual resources for non-English speaking family members or caregivers, and plain language and visual resources for low-English literacy clients.
“… most of our clients are Bengali, and we didn’t have… a chart to transition them from puree food into finger foods or family foods. … the charts we did have very much… Australian foods and things like that. … So I think the resources are very much lacking in, you know, information about their culture and what they eat, so we can address it from their point of view...”
(Interviewee #15)
Resources to support families were also needed, such as infant and early childhood recipes from reliable resources; basic recipes for clients with low food literacy; parenting resources such as play equipment and toys for low-income clients; and establishment of structured health promotion programs for young children up to five years of age, similar to preventive health programs for school-aged children [47].
“…to exercise floor time and tummy time, on the floor, I often go in, and if a family can’t buy their or provide their mats [for infant exercise], then I’ll give rubber mats or yoga mats.”
(Interviewee #6)
Interviewees also suggested that information given to parents should be more positive and aim to correct parents’ awareness of physical activity levels for children and benefits of limiting screen time, independent of weight issues.
“But with lots of parents, we do see stick their kids in front of the TV, to distract them, and to get their… housework done, and things like that. So, we try and incidentally make comments, you know, like, ‘ah, yes, it’s good that baby’s got great eye contact, but she shouldn’t be watching TV and it’s not good for their eyes, their development’. Usually, if you put it in, like, their development of their eyes, they tend to listen more, like it’s going to affect their brain.”
(Interviewee #12)
Nurses discussed the merits of electronic resources (websites or apps) for parent education, particularly the need for these to be approved by health care practitioners and the difficulty of encouraging parents to use recommended sites.
“We have very strict guidelines—they go through our clinical quality meeting. … We do have, I think, three apps on our recommended list at this time.”
(Interviewee #1)
Nurses were concerned about the cost of paid apps or in-app purchases, and internet access for low-income families. One interviewee highlighted the irony of recommending web-based resources:
“I suppose my only concern is that when we're sort of encouraging parents to use websites and apps, we're sort of condoning and using their own phone and their own devices. And then we're telling them on the other hand, to stop using their devices and pay attention to their children.”
(Interviewee #3)