An Exploratory Look at the Role of Childcare Providers as a Support and Resource for Breastfeeding Mothers

Abstract

Introduction:

The childcare setting remains largely unexplored as a potential barrier to breastfeeding continuation and, therefore, the lack of interventions targeting childcare providers may be a missed opportunity for improved breastfeeding support. This article explores the perceptions of 25 first-time breastfeeding mothers on navigating the critical transition to childcare and the role of childcare providers regarding breastfeeding support.

Methods:

Mothers were selected if they indicated an intent to breastfeed on a prenatal questionnaire and had enrolled their child in childcare. Semistructured interviews guided by Bronfenbrenner's bioecological model were conducted to capture mothers' experiences. Responses were analyzed utilizing thematic analysis to generate themes rooted in mothers' experiences with childcare and breastfeeding.

Results:

A thematic analysis resulted in three key themes: Providers are not Critically Evaluated, A Stressful Transition, and Childcare as a Service, not Support. These themes indicated that although mothers intended to continue breastfeeding during and after the transition to childcare, they had not previously given much consideration to the childcare setting beyond that of a service provider.

Conclusion:

Findings illustrate new considerations to support modern breastfeeding mothers through the transition to work and childcare are needed such as basic and practical education and training to prepare childcare providers to support breastfeeding mothers in the way that best meets their needs, enhanced education for mothers on how to seek and evaluate providers for breastfeeding competence, and policy initiatives focused on fostering engagement between mothers and providers. By taking mothers' perceptions into consideration, researchers, practitioners, and policymakers can offer breastfeeding support that mothers will be receptive to and more likely to engage with, thereby advancing the health of both mothers and infants.

Introduction

Over the last two decades, efforts to reinforce breastfeeding promotion and strengthen breastfeeding resources and education have generally propelled rates of breastfeeding upward.¹ However, mothers in the United States are still breastfeeding less, and for a shorter duration than recommended.^2,3 Many benefits of breastfeeding are fully realized through exclusivity and duration.^3,4 For this reason, improving exclusive breastfeeding duration to 6 months has been a national goal as part of both the Healthy People 2010 and 2020 initiatives, yet national estimates indicate that less than 25% of mothers currently reach this goal.⁵ Despite a growing body of evidence regarding barriers and facilitators to breastfeeding continuation,^6–8 an evident discrepancy between the rates of breastfeeding initiation and duration remains.^5,9

Recently, the CDC has recommended improving support for employed women as one of three main strategies for increasing breastfeeding rates.⁹ As nearly half of U.S. children <1 year of age participate in nonparental care,¹⁰ one aspect of supporting employed mothers, who depend on childcare providers upon their return to work, may be to improve breastfeeding support from childcare settings. In the CDC's Strategies to Support Breastfeeding Mothers and Babies, Early Care and Education (ECE) settings are one of eight targeted areas of focus to increase support for breastfeeding mothers and infants.¹¹ The rationale behind this strategy is sourced from national guidelines for ECE programs set forth by the American Academy of Pediatrics and the American Public Health Association,¹² which postulate that childcare providers are an important support for breastfeeding mothers upon the return to work.

A small body of literature suggests a relationship between childcare use and shorter breastfeeding duration. The longitudinal Infant Feeding Practices Study II surveyed mothers who had breastfed and used childcare about five potential breastfeeding supports from childcare providers.¹³ Mothers who reported receiving all five supports were thrice as likely to be breastfeeding at 6 months, compared to mothers who felt they received fewer than three of these supports. In another study, an exploration into the association between childcare use, WIC participation, and breastfeeding duration found childcare use to be an independent risk factor for short breastfeeding duration.¹⁴

These findings form a basis for this study and warrant further exploration into the role of childcare in mothers' breastfeeding experiences and efforts. Research has yet to examine how mothers traverse the transition to childcare and assess how mothers perceive childcare in relationship to breastfeeding. The purpose of this exploratory study is to examine first-time breastfeeding mothers' perceptions of the ability to follow through on the intent to breastfeed, experiences of transitioning to childcare, and the role of childcare in breastfeeding.

Methods

Design and participants

Given the lack of evidence on this multifaceted topic, a semistructured interview was used to guide data collection.^15,16 This study was approved by the Institutional Review Board at the University of Illinois at Urbana-Champaign.

All participants were recruited from a larger, on-going birth cohort study examining the determinants of childhood obesity during early childhood.¹⁷ Potential participants were contacted if they responded “Breastfeed” to the question, “Which of the following do you intend to do after the baby is born?” as part of the prenatal registration questionnaire, also indicated their infant would attend nonparental, nonrelative childcare (defined as daycare center, in-home daycare, or nanny), had started childcare at the time of the interview, and were first-time mothers.

Theoretical framework and semistructured interview protocol

To guide the development of the interview protocol, the researchers situated the development and evolution of the breastfeeding decision within Bronfenbrenner's bioecological model.^18,19 If mothers interact and partner with providers in the childcare setting, childcare becomes an element of the mother's mesosystem, thereby fostering the opportunity to seek and receive breastfeeding support and lead to positive breastfeeding outcomes. Therefore, the goal of the interview was to understand how mothers with prenatal intent to breastfeed experienced childcare within the larger framework of their overall breastfeeding journey. Questions were developed using the literature on barriers and facilitators to breastfeeding as a guide such that, in addition to questions regarding childcare and breastfeeding, each section contained items designed to address times, supports, and resources known to be important for breastfeeding initiation and duration.

The interview protocol was reviewed by a panel of experts in the field of breastfeeding, nutrition, and childcare, and pilot tested with two first-time mothers who met the eligibility criteria, but were not enrolled in the larger birth-cohort study. Minor changes were made to the protocol to enhance item clarity.

Data collection

Twenty-five in-person semistructured interviews were conducted from August 2015 through March 2016. The interviews averaged 80 minutes and were most often conducted in the participant's home. The concept of saturation was employed to determine the number of interview participants. Saturation is achieved when subsequent interviews fail to reveal new information on the topic being explored.²⁰ The research team agreed that saturation had been reached at 20 interviews. An additional five interviews were conducted to ensure saturation was achieved.

Data analysis

Interviews were digitally recorded and professionally transcribed and compared against the audio recordings for accuracy by the researchers. Transcripts were imported into the qualitative data analysis program Dedoose.²¹ A six-step thematic analysis approach as outlined by Braun and Clarke¹⁵ was utilized to generate themes rooted in mothers' experiences with childcare and breastfeeding. Four members of the research team first generated a list of initial codes independently and then discussed differences between codes. Differences were reconciled and an initial codebook was created. The team coded transcripts independently using the codebook and met intermittently as a group to discuss all coded excerpts, resolve differences, propose additions to or discrepancies in the codebook, and explore potential themes. Consensus meetings allowed the group to work through a natural checks-and-balances system to eliminate any individual bias, compare and contrast the strength of evidence for final codes and themes, and uncover nuances within the data through such an iterative process. The goal was to accurately define the common experiences and emotions had by the mothers as well as to reflect the collective nuances present within those responses in a meaningful way.

Results

The final sample was composed of non-Hispanic white (92%), highly educated (75% college graduate/postgraduate work), and married (79%) women. Most mothers transitioned their infant to nonparental childcare at an average age of 10.4 weeks and 68% were breastfeeding (expressed breast milk, direct breastfeeding, or both) at the time of transition to care. At the time of the interview, 44% of mothers were still providing breast milk, which could be in combination with solid foods and/or water for older infants (Table 1). The following three themes were identified in mothers' reflections on their experiences with, and perceptions of, breastfeeding and navigating the transition to childcare (Table 2).

Table 1.

Demographic and Feeding Characteristics of (n = 25) First-Time Breastfeeding Mothers

Characteristic	n	%
Race
Non-Hispanic White	23	92
Non-Hispanic Black or African American	1	4
Non-Hispanic White and Asian	1	4
Age
18–24	3	12
25–29	12	48
30–37	10	40
Education
Grade school/high school/high school graduate	1	4
Some college or technical school	5	21
College graduate/postgraduate work	18	75
Income
$3,000 and under	3	13
$3,001–$5,000	8	35
$5,001 and above	12	52
Marital status
Single	4	17
Married	19	79
Co-habitating	1	4
WIC
Mother and infant	1	4
Mother	1	4
Infant	1	4
Delivery method
Vaginal	20	80
Unplanned C-section	4	16
Planned C-section	1	4
Child feeding method at 1 week of age
Exclusive breastfeeding	19	76
Exclusive formula feeding	0	0
Both	6	24
Child feeding method at 6 weeks of age
Exclusive breastfeeding	17	68
Exclusive formula feeding	3	12
Both	5	20
Child feeding method at 3 months of age
Exclusive breastfeeding	15	60
Exclusive formula feeding	5	20
Both	5	20
Child feeding method at 12 months of age
Breast milk	9	36
Formula	9	36
Both	2	8
Neither	4	16
Missing	1	4
Feeding method at time of interview
Breastfeeding	11	44
Formula	5	20
Both	5	20
Neither	4	16
Feeding method at time of transition to nonparental care
Breast milk	17	68
Formula	2	8
Both	6	24
Child age at transition to nonparental care
4–6 weeks	7	28
7–12 weeks	16	64
>12 weeks	2	8

Table 2.

Themes and Subthemes Regarding Breastfeeding Mothers' Perceptions of Choosing and Transitioning to Childcare

Theme 1: Providers are not Critically Evaluated
Providers are not Critically Evaluated was informed by four subthemes: Provider as Expert, Lack of Knowledge, Misconceptions about in-home Childcare, and Low Priority:
Provider as Expert Mothers started the process of looking for and transitioning to childcare under the assumption that all providers were knowledgeable about breastfeeding.	“What were my thoughts about her (child) feeding? I thought that they (providers) would know what they were doing. Because I guess I just anticipated that if you were in daycare and you were certified, you would know that.”—Mother 8
	I have no idea what she (provider) does during the day. I send food in and it's either eaten or not, so I don't know if she implements kind of her own—she has two girls that are in high school so she's raised her own kids.—Mother 2
Lack of Knowledge Mothers didn't know what questions to ask regarding breastfeeding accommodation.	“I wouldn't have even thought to ask, but sooner or later, one of the places—somehow feeding came up during the interview… she flat out said, ‘I won't accept frozen milk.’ Some of the daycares absolutely refuse to do frozen breast milk—like, absolutely refuse. They said that they did not feel comfortable with it, they only wanted to feed formula.”—Mother 6
Misconceptions about in-home Childcare First-time mothers may hold a misconception about in-home childcare as safer, more trustworthy, or provide more individualized attention without consideration of provider qualities such as education/training related to child care or feeding breastfed infants.	“I was a little concerned at a center, how the feeding would occur because, there's so many more kids in a center. And in-home, with fewer kids, I knew that he'd eventually be getting his bottle, and I guess I just felt more comfortable sending my breast milk to where there's not tons of other breast milk being stored and given.”—Mother 13
Low Priority First-time mothers are navigating many new experiences when breastfeeding and transitioning to childcare, therefore, it makes sense that mothers prioritize any sense of familiarity in a new childcare provider and may compromise other qualities, such as breastfeeding knowledge, to gain the comfort of safety and trustworthiness.	“I would say our top priority was probably finding someone who we were comfortable leaving her in the care of… and so we figured this woman…she's perfectly capable of managing her three kids and our one. So we feel very comfortable with her mothering abilities and her parenting decisions. And so that was our top priority.”—Mother 7
	I really didn't research daycare centers. I knew they'd be too expensive regardless of—I just wanted—I don't know. I mean, knew I wanted a female watching him and I really didn't do much research. I just kind of found someone that I knew from high school who I knew who was doing child development. And I was like, “Okay, I choose you.”—Mother 11
Theme 2: A Stressful Transition
A Stressful Transition was informed by two subthemes: New Relationship and Pumping as a Sacrifice:
New Relationship Mothers discussed challenges met with adjusting to breastfeeding continuation and often talked about their breastfeeding relationship as more so with their pump rather than their infant.	“I think it (breastfeeding) was a lot easier without pumping. Like I said, once you got into a routine—at first, it was hard to pump and find time to pump, and it was a little stressful, just having to produce so much, and he's huge, so he eats a lot. So, that stressed me out a little bit. But once we really have gotten into a routine, it hasn't been bad at all.”—Mother 8
Pumping as a Sacrifice Most mothers said they didn't enjoy pumping and discussed feelings of sacrificing time, freedom, and/or work, even though they felt like it was something worthwhile they were doing for their child.	“Pumping it was a necessary thing to do. I would say it's just a pain because you have to take the time to sit and do it, and then it was uncomfortable… Then you have to take the time to wash everything, and then bring it home, and then transfer it to be frozen… and then send to school (childcare) the next day to remember to defrost the old milk to keep in rotation.”—Mother 3
Theme 3: Childcare as a Service, not Support
Childcare as a Service, not Support was informed by two subthemes: Unconditional Support and Disconnect from the Childcare Setting:
Unconditional Support It seemed that mothers did not find the providers' beliefs or values related to feeding to be necessarily important. Mothers defined support as providers doing what they wanted or needed them to do.	“Yeah, I mean, it was, “However you want to do it, this what you need to give us.” I don't think they're against them (values or beliefs), but I don't know. Yeah, I mean supportive in the fact that they want to honor whatever we want them to do type thing, like the schedule.”—–Mother 10
	“She was just willing to feed him whatever I thought was best—no questions asked.”—Mother 13
Disconnect from the Childcare Setting Mothers described their relationships with providers as transactional in nature, indicating that communication and interaction with providers regarding feeding is limited or brief. Often this communication is an exchange of pertinent information to facilitate drop-off and pick-up.	“I really don't know what exactly they're doing when they're feeding him. But they seem to—he's not malnourished. You saw him. He's a big baby. He's fine.”—Mother 11
	“So probably the most day-to-day (communication) is just through—there's a little sheet so anytime he has a wet diaper or they feed him a bottle or he had breast milk or whatever, they would just write down how much it was at what time.”—Mother 16

Providers are not critically evaluated

Mothers did not recall explicitly seeking or receiving breastfeeding-related information about providers or seeking or choosing breastfeeding-competent providers. When asked what characteristic(s) were the most important in a provider, nearly all mothers noted concerns of safety, trustworthiness, and familiarity of a provider, but few prioritized or mentioned providers' ability to accommodate breastfeeding. One mother explained she was looking for the following:

“Just someone that I had a good gut feeling about…just something that, I just wanted to make sure that I felt good about them, felt good about the place where he would be, that it would be safe, and be taken care of. Really as long as that was, I could handle anything else, but as long as he's being taken care of.”—Mother 2

Furthermore, mothers generally presumed that all providers were knowledgeable about breastfeeding:

“I did mention to the teachers that I would be coming over to nurse him and [asked] were they okay with that? ...And that they would be feeding him at least one bottle a day, but that's really all. I didn't ask them about procedures or anything like that, I just assumed they were competent in their jobs.”—Mother 23

Thus, it appears that instead of asking breastfeeding-specific questions of providers, most mothers focused on other characteristics of providers as support for competency in handling breast milk or the ability to accommodate breastfeeding. The most commonly cited was years of experience in childcare or raising children:

“Yes, I asked her, like, is it okay, when it comes to bringing expressed milk, how do you want it brought to the house? Do you want it already in the bottle or is it okay to come in the bags? That was about it… but she has done daycare for 30 years, so she seemed to know how it worked.”—Mother 17

Many mothers did not identify a lack of knowledge or evaluation of providers' qualifications as problematic for breastfeeding continuation. However, some mothers had to “learn on the job” how important it was to ask breastfeeding-related questions, for example,

“Had I not gone to the facilities, I wouldn't have known because they ask, “Are you going to breastfeed or are you going to formula feed?” And I never realized that that would be a question. So then when I went [and] did in-home [interviews]…I asked about breastfeeding—are they used to it or whatnot? And so the current one, where she's at now, was not used to breastfeeding, and she was more than willing to learn, and I gave her some information from the clinic, and have not had any issues.”—Mother 8

A stressful transition

Recent research and national guidelines to promote and support breastfeeding acknowledge the additional support needed for working mothers who wish to continue to breastfeed.^9,22 Mothers' responses highlight a complicated relationship where childcare as a new routine is established and emphasize the time surrounding the transition to childcare as a key window of opportunity where improved supports could be offered from childcare providers. For example, when asked to describe their experiences with breastfeeding and childcare, one mother explained the following:

“It's the one thing that stresses me out I would say. Because I feel like I need to have three bags of milk ready for twice a week and I usually don't. But…if he were with me I wouldn't have to worry about this. So it's kind of a struggle of like should I be working? It brings up a whole lot of other issues… There are times where I'm just like, forget it. It would be a lot easier if we just did straight formula.”—Mother 19

Pumping was harder and more time-consuming than mothers expected it to be and they discussed the challenges of managing the extra work pumping and supplying breast milk for childcare required:

“I didn't think I would (breastfeed) after she was put in daycare just because I had already heard it was so difficult and then to put pumping on top of it, I thought, would make it even more difficult, so at first, I had planned on just stopping whenever I went back to work.”—Mother 17

Mothers described a change in their relationship with breastfeeding, further highlighting the challenges met upon transitioning to childcare:

“For the first six weeks, it was just breastfeeding, and then there was that transition to childcare where I tried keeping it up at home. That didn't work. Then I pretty much switched to just pumping. That's where she is now. We just give her pumped milk.”—Mother 20

“I think it was he (child) wasn't there all the time, so I guess my relationship was more intimate with my pump, right?”—Mother 16

Childcare as a service, not support

A common thread woven throughout mothers' responses was that the predominant experience of childcare was from the perspective of a service only. Mothers seemed to approach childcare as patrons paying for a professional service, and rarely discussed partnerships or relationships with providers beyond that of caregiver. Although childcare is a paid service, childcare providers are unique compared to other types of service providers. Leading health organizations recognize providers' role as vital and influential in the health and lives of children and their families.^23,24 The national Guidelines for Early Care and Education Programs further emphasizes that appropriately trained childcare staff have a responsibility to be mothers' cheerleaders and enthusiastic supporters regarding breastfeeding.¹² Contrary to this definition of providers as key partners in mothers' breastfeeding experiences, mothers did not talk about providers' beliefs or values related to feeding to be a necessary component of support:

“I'm not sure, I don't know, and I don't really care. I don't know…I have the feeling sometimes that she (provider) wouldn't do the pumping for example (if she were feeding her own child). She would also not go [back] to work…I never asked her. There might be some differences in values, but she's really good with just, she really values the fact that we want to do it a certain way and she does it, so that's good, yeah.”—Mother 22

Although mothers most often answered “yes” when asked if they felt support from their provider, they struggled to describe this type of support when probed. Nearly all the mothers defined support as providers' willingness to do whatever they wanted or needed them to do regarding feeding their child:

“I mean, she was supportive. She didn't care whatever I wanted to do. If I wanted to breastfeed and bring milk, she was okay with it. If I wanted to bring formula, that's okay. If I wanted to use hers, that's okay as well, too. So she was very open.”—Mother 4

Although following mothers' feeding plans is an important aspect of breastfeeding support,¹¹ mothers indicated little follow-up to understand if providers were doing so. Mothers' responses indicated they did not consider themselves to be part of infants' childcare environment and lacked connection to the childcare setting. For example, mothers relayed having little knowledge about what occurs at childcare, especially in relation to details surrounding feeding:

“I know that they keep a freezer, so I just bring in a cooler every couple weeks, and they put it (breast milk) in the freezer, and by the end of the day, I get the cooler back, so I certainly hope it's going well. But I don't know. They must be up to code. I'm not sure how they're doing it, though.”—Mother 25

Discussion

Breastfeeding mothers' perceptions of the childcare setting have been overlooked

It was surprising to learn that in relation to breastfeeding and breastfeeding support, mothers predominantly viewed childcare from a neutral perspective of providing them a service. Our findings suggest that mothers may view childcare as part of their exosystem, whereby the provider is simply meeting the need for caregiver rather than part of a mesosystem partnership of caring for the child. Mothers may not seek support from or engage with the childcare setting if childcare is considered to be outside of the immediate supports within their microsystem. This explanation would draw into question how current policy efforts¹¹ perceive childcare environments in relation to breastfeeding.

So far, these considerations have overlooked breastfeeding mothers' perceptions of providers. For example, there remains no empirical evidence that breastfeeding mothers choose breastfeeding-supportive providers (e.g., Batan et al.¹³). In contrast, our findings suggest that mothers are not perceiving childcare as a source for breastfeeding-specific support, are more focused on receiving safety, trustworthiness, and familiarity from a provider, and do not seek partnerships with providers. Although mothers did not explicitly call out childcare as a barrier to continue breastfeeding, it is evident that mothers do not view childcare as a potential support environment, either. Beyond providers doing what mothers have paid for them to do, mothers did not describe interacting with childcare as partners in infant feeding in the ways described within key guidance documents.^11,12

First-time mothers are navigating many new experiences when breastfeeding and transitioning to childcare; therefore, it makes sense that mothers prioritize a sense of security in a new childcare provider and may compromise other qualities, such as breastfeeding knowledge. However, mothers also indicate not knowing what questions to ask regarding breastfeeding accommodation, assuming that all childcare providers are equally qualified and may have more knowledge and experience than themselves regarding feeding and caring for children. Therefore, it may also be that the majority of mothers remained unaware of potential differences in, or the availability of, breastfeeding support from childcare providers and, therefore, did not feel they needed to critically evaluate providers regarding breastfeeding.

These results suggest mothers may not be empowered to look for breastfeeding-supportive providers, as mothers also indicated a lack of interaction with childcare and with providers. A lack of partnership on behalf of both mothers and providers may mean that mothers miss out on key opportunities for support. Current guidelines and recommendations for promoting breastfeeding within ECE settings need to reevaluate the methods of delivery of breastfeeding support to foster engagement between mothers and providers.

Childcare providers are not meeting mothers' expectations

Part of mothers' “hands-off” approach to the details of what occurs within childcare and lesser relative valuation placed on providers' breastfeeding accommodation or support, may be partially explained by their perception of providers as childcare experts.

These findings are concerning given that most providers lack structured and mandatory breastfeeding education and training. For example, Clark et al.²⁴ surveyed infant-care providers and directors and found that nearly 80% had low levels of knowledge of preparing and storing breast milk properly. Furthermore, a study assessing childcare providers' knowledge and attitudes related to breastfeeding support found that most providers felt breastfeeding promotion in childcare should focus on targeting parents rather than staff, even though results of the survey found staff to have low overall breastfeeding knowledge and the majority lacked feelings of efficacy in supporting breastfeeding mothers.²⁵ At the policy level, a recent national review found that no state had regulations consistent with all five state-licensing recommended standards for supporting breastfeeding in childcare.²⁶ This research, together with the current findings, illustrates the variability of breastfeeding support efforts within and across childcare settings.

Our results highlight a mismatch between how mothers perceive childcare and how providers are trained. Childcare providers assume the role of expert in the eyes of the first-time breastfeeding mother and therefore, there is a need for basic and practical breastfeeding education and training for providers. Childcare settings should be upfront about how knowledgeable and equipped they are to handle breastfed infants, and how they are prepared to support breastfeeding mothers in the way that best meets mothers' needs.

Limitations and future directions

The findings of this study must be interpreted within the scope of its limitations. Only mothers' perspectives were examined. Future research should examine the perspectives of providers on feeding breastfed infants and supporting breastfeeding mothers. In addition, these findings do not represent a diverse sample and cannot represent the larger population of all first-time breastfeeding mothers. While the ability to make broad generalizations based on these results is impeded, these findings can serve to inform survey design for larger data collections.

Despite these limitations, this study provides valuable insight for guiding improvement of accessible breastfeeding support, and illustrates the need for future research exploring the childcare setting as a critical factor in efforts to promote breastfeeding continuation. These results strongly suggest that future policy initiatives should consider breastfeeding support within the childcare setting from a systems perspective—focusing on fostering relationships between ECE settings and breastfeeding mothers rather than taking a top-down approach. From this perspective, efforts to improve breastfeeding support within childcare should focus on ways to educate providers on both practical breastfeeding knowledge and strategies for reaching out to and engaging breastfeeding mothers in support relationships.

Conclusion

To our knowledge, this study is the first to examine how breastfeeding mothers perceive and navigate the critical transition period to childcare. It is evident that the shift in the mother-infant relationship involving work and childcare was a significant stress for the first-time mothers in our study and impacted their breastfeeding experience. Although mothers did not directly implicate childcare as a cause of this difficulty, they also did not indicate that providers served to support them or mitigate their stress. Furthermore, mothers did not recall being offered breastfeeding information or support from providers. While breastfeeding mothers did not prioritize breastfeeding support when choosing providers, the difficulties encountered during the transition to childcare suggest that there is a missed opportunity for providers to play a positive role in supporting breastfeeding continuation. We might expect a natural relationship or partnership to form between childcare provider and mother; however, our findings counter this conception, bringing forth new considerations for approaches to provider education and policy efforts that seek to improve breastfeeding support in ECE settings. Mothers should feel empowered to seek breastfeeding-supportive providers and providers should be given the responsibility to make such a relationship available through improved education and engagement. Mothers may be more receptive to, and more likely to engage with, breastfeeding support opportunities when researchers and policymakers take mothers' perceptions into consideration.

Footnotes

Acknowledgments

This research was supported, in part, by an Agriculture and Food Research Initiative of the USDA National Institute of Food and Agriculture AFRI Childhood Obesity Prevention Challenge grant (2011-67001-30101) to the Division of Nutritional Sciences at the University of Illinois, and a grant from the University of Illinois Research Board (RB15134).

Disclosure Statement

No competing financial interests exist.

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