Health Care Providers

Feeding guideline documents most often focused on health care providers as a critical nexus for changing caregiver practice. The guideline documents reviewed by the committee often sought to promote awareness, attitudes, knowledge, and the adoption of feeding recommendations at the individual provider or practice level. Some guideline documents included additional or external resources for health care professionals (AAFP, 2014; AAP Section on Breastfeeding, 2012; AND, 2016; Ministry of Health, 2012; NHMRC, 2012; NICE, 2008; RCPCH, 2019). Three guideline documents included explicit discussion points that could be used to communicate the recommendations to families (Baker-Smith et al., 2019; Health Canada et al., 2014, 2015). Three mentioned adapting the information within the guideline document to be more relevant or messaged appropriately (New Zealand Dental Association, 2008; PAHO/WHO, 2003; WHO, 2005).

Parents and Guardians

Although the importance of providing parents and guardians with specific feeding guidance was acknowledged, these groups were infrequently the target audience for the guideline documents reviewed. Only two of the guideline documents, both from the Robert Wood Johnson Foundation-Healthy Eating Research (RWJF-HER), specifically mentioned parents and guardians as a target audience (Lott et al., 2019; Pérez-Escamilla et al., 2017). Lott et al. (2019) sought to “provide consistent messages that can be used by health care providers, public health practitioners, and parents and caregivers.” The publicly accessible webpage that hosts the guideline document includes a synopsis, along with an infographic that distills the recommendations and presents them by age group (HER, 2019). Similarly, Pérez-Escamilla et al. (2017) aimed to “empower caregivers to address the nutrition and well-being of infants and toddlers.” On the webpage that hosts the Pérez-Escamilla et al. (2017) guideline document (HER, 2017), there is a link for a series of 12 videos for parents (1,000 Days, 2020); the video webpage was a collaborative effort among the Centers for Disease Control and Prevention, RWJF-HER, and 1,000 Days that provides “accessible and evidence-based information about what, when, and how to feed infants and toddlers.”

Two of the guideline documents provided additional resources or tools specifically for parents and guardians, despite parents and guardians not being a primary target audience of the guideline document itself. The end of a guideline document from the Canadian Paediatric Society (CPS) listed three references as being “resources for parents” (Grueger et al., 2013). The 2017 Addendum Guidelines for the Prevention of Peanut Allergy in the United States included an appendix providing parents and guardians with instructions for feeding peanut protein to low-risk infants at home (Togias et al., 2017). Two guideline documents authored by a consortium of Canadian organizations—Breastfeeding Committee for Canada, CPS, Dietitians of Canada, and Health Canada—were more indirect with regard to guidance for parents (Health Canada et al., 2014, 2015). Both guideline documents provided information and ideas about how to answer the questions of parents and caregivers, but they did not provide direct communication tools for this audience in these online resources.

A host of online resources are available to parents and guardians, but they are sometimes inconsistent in directly mapping back to a guideline document. For instance, one of the Canadian consortium partners, CPS, used its guideline documents in its own communication and dissemination efforts. CPS hosts a website to provide information directly to parents (CPS, 2020). The webpage on breastfeeding provides detailed information for mothers and provides links to additional resources (CPS, 2018), two of which were the collaborative guideline documents in which it participated (Health Canada et al., 2014, 2015). CPS's parent and guardian guidance on vitamin D (CPS, 2016) also hyperlinks the organization's position statement on the topic (Godel et al., 2007). AAP also hosts a parenting website (AAP, 2020). Although the website includes guidance on feeding infants and young children, the guidance does not directly map back to specific guideline documents.

Early Care and Education (ECE) Providers

Despite being integral players in infant and young child feeding, ECE providers were often not the target audience of the guideline documents the committee reviewed. Only one guideline document specifically mentioned ECE providers (Pérez-Escamilla et al., 2017), and none exclusively focused on ECE providers as the primary audience. Nevertheless, ECE providers are not without guidance; a number of resources related to infant feeding are available to this audience.

In the United States, a key resource available to ECE providers and others who care for children is Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs (Caring for Our Children) (AAP et al., 2019). Caring for Our Children is a collaborative effort among AAP, the American Public Health Association, and the National Resource Center for Health and Safety in Child Care and Early Education; it contains national standards that “represent the best evidence, expertise, and experience in the country on quality health and safety practices and policies that should be followed in today's early care and education settings” (AAP et al., 2019, p. xvii). Many of the standards in Caring for Our Children focus on how, what, and when to feed infants and young children. Although not the primary source of feeding recommendations, Caring for Our Children was designed to reflect guidance put forth by other authoritative organizations like AAP, the federal Child and Adult Care Food Program (CACFP),² or federal nutrition guides from the U.S. Department of Agriculture (USDA). The specific guidance in the standards, however, does not always directly map to guideline documents or federal standards, although references are provided. In addition to the primary Caring for Our Children document, there are a number of other ancillary resources to help ECE providers implement the standards (e.g., tip sheets). Thus, Caring for Our Children serves as an example for how feeding recommendations from authoritative bodies are translated and then communicated and disseminated to “on the ground” providers in ECE settings through both a primary comprehensive resource and secondary materials to help providers implement the standards.

Program Administrators

Program administrators play an important role in implementing feeding guidance and serving as a conduit for information for both program participants and staff. Across the guideline documents the committee reviewed, few noted program administrators as a key target audience. Those that did envisioned that the recommendations would inform and serve as the basis for health and nutrition programs (Ministry of Health, 2012; PAHO/WHO, 2003; WHO, 2005). As is the case for ECE providers, there are important documents that specifically communicate and disseminate feeding guidance to program administrators, but they largely exist outside of the guideline documents the committee reviewed. Two U.S. national programs with such guidance are CACFP and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

Administered by the USDA Food and Nutrition Service (FNS), CACFP provides reimbursement for eligible meals and snacks served to qualifying children in participating ECE programs.³ USDA recently revised the CACFP rule to include a number of updates to improve children's nutritional intake to better align with the Dietary Guidelines for Americans, as required by the Healthy, Hunger-Free Kids Act of 2010 (USDA, 2016). The recent CACFP rule changes guidance to program administrators on meeting the new requirements. One way in which this information was communicated to program administrators was through the document Feeding Infants in the Child and Adult Care Food Program (USDA-FNS, 2019a). This resource provides extensive practical information on how to comply with the new rule, and includes resources such as meal patterns, pictures, and example vignettes. Feeding Infants in the Child and Adult Care Food Program is an example of how feeding recommendations, together with policies and federal regulations, are synthesized and communicated to program administrators.

WIC, also administered through USDA-FNS, provides “nutritious foods to supplement diets, nutrition education (including breastfeeding promotion and support), and referrals to health and other social services” to low-income, nutritionally at-risk women, infants, and children up to age 5 (USDA-FNS, 2020). USDA-FNS recently released Infant Nutrition and Feeding: A Guide for Use in WIC (USDA-FNS, 2019b), designed to be a research-based resource for WIC staff who counsel program participants. The guide notes it “can assist staff in disseminating appropriate and accurate information to participants. It is a resource for planning individual counseling sessions, group classes, and staff in-service training sessions” (USDA-FNS, 2020).

Policy Makers

The guideline documents summarized in Table 6-1 that identify policy makers as a target audience did not appear to be designed to reach policy makers directly (Fidler Mis et al., 2017; NICE, 2008; PAHO/WHO, 2003; RCPCH, 2019; SACN and COT, 2018; WHO, 2005). Each included only a brief reference to policy makers. For example, a guideline document for the UK government on the introduction of peanuts and hen's eggs into infant's diets included a brief section on recommendations for government that states:

The government should continue to recommend exclusive breastfeeding for around the first 6 months of life…. Advice on complementary feeding should state that foods containing peanut and hen's egg need not be differentiated from other complementary foods. Complementary foods should be introduced in an age-appropriate form from around 6 months of age, alongside continued breastfeeding, at a time and in a manner to suit both the family and individual child…. The deliberate exclusion of peanut or hen's egg beyond 6 to 12 months of age may increase the risk of allergy to the same foods. Once introduced, and where tolerated, these foods should be part of the infant's usual diet, to suit both the individual child and family. If initial exposure is not continued as part of the infant's usual diet, then this may increase the risk of sensitisation and subsequent food allergy…. Families of infants with a history of early-onset eczema or suspected food allergy may wish to seek medical advice before introducing these foods. (SACN and COT, 2018, pp. 11–12)

Similarly, a Royal College of Paediatrics and Child Health (RCPCH) guideline document noted that the organization “strongly support[s] national policies, practices, and legislation that are conducive to breastfeeding” (RCPCH, 2019, p. 3). In addition, the document contained specific calls to action for policy makers by stating, for instance:

RCPCH calls on: The NHS [National Health Service] in England and the Welsh Government to follow the lead of the Scottish Government and the NHS in Northern Ireland by requiring all maternity services to achieve and maintain Unicef U.K. Baby Friendly Initiative accreditation; this requirement is currently met by all maternity units in Scotland and Northern Ireland. (RCPCH, 2019, p. 4)

The guideline documents the committee reviewed provided a few examples of approaches to communicating the recommendations directly to policy makers. One approach taken was to clearly identify the government as the entity that needed to carry out the recommendation. This strategy is contingent on policy makers identifying and understanding the guideline recommendation. Another approach was an organizational call to action for policies that support the recommendation.