Abstract
Background:
Nearly 74% of U.S. mothers work full-time and employment is a cited reason for stopping breastfeeding. In the effort to increase breastfeeding duration, childcare providers could facilitate continuation of human milk feeding when mothers return to work. Yet, mothers report receiving little support when transitioning infants into childcare.
Objective:
Explore the themes of comfort with human milk and formula feeding among childcare administrators near Tampa, Florida.
Material and Methods:
Twenty-eight childcare administrators participated in semistructured interviews regarding policies and perceptions about infant feeding practices at their center. Using Applied Thematic Analysis, interview themes were identified.
Results:
Most administrators agreed “breastfeeding is best.” However, they expressed discomfort with mothers breastfeeding at the center and perceived risk with handling and feeding human milk. These perceptions are illustrated through the theme “Formula feeding is normative” and four emergent subthemes: “Human milk is potentially harmful,” “People are uncomfortable with breastfeeding in public,” “I'm not the expert,” and “‘Breastfeeding is best’, in theory.”
Conclusion:
While breastfeeding may be best for health, from the childcare administrators' perspectives, it may not be best for the childcare environment. A cultural shift may be needed to change norms and perceptions in the childcare environment to support mothers in their effort to provide human milk. Perhaps it is time for a new message, such as “We can help you.”
Introduction
Due to numerous benefits of human milk production, lactation, and consumption to both maternal and child health, the World Health Organization, 1 American Academy of Pediatrics, 2 and other health organizations 3 recommend exclusive breastfeeding for 6 months with continued breastfeeding with the introduction of complementary foods for the first 1 to 2 years of life. Most infants in the United States, however, are not meeting these breastfeeding goals. While ∼83% of U.S. infants initiate breastfeeding, only 25% are exclusively breastfed for 6 months 4 and 36% are breastfeed for at least 1 year. 4 One frequently cited reason for the drop in U.S. breastfeeding rates is maternal employment.5–8 Fifty-eight percent of U.S. mothers with infants are in the labor force, 9 and nearly three-quarters of employed U.S. mothers with infants work full-time. 9
Given 47% of U.S. infants regularly receive some form of nonparental care, 10 childcare providers have the potential to either exacerbate the negative effects of employment on human milk feeding or facilitate continued human milk feeding after mothers return to work. Some childcare providers lack knowledge about breastfeeding, 11 which could make it difficult to support breastfeeding mothers. Yet, childcare provider support for breastfeeding is positively associated with breastfeeding duration at 6 months. 12 A recent article by Lundquist et al. 13 found that breastfeeding mothers experienced many stressors and little support when transitioning their infants into childcare. The authors suggest researchers should (1) investigate childcare workers' perceptions of “feeding human milk to infants in explore childcare, and supporting breastfeeding mothers,” and (2) “explore childcare settings as a source of support for breastfeeding mothers.” 13 This data analysis is a response to their call. 13
Recognizing the potential role that childcare providers could play in supporting breastfeeding exclusivity and duration, in 2011, the U.S. Surgeon General recommended the training of childcare providers in the use of human milk and the adoption of national standards for breastfeeding support within childcare centers. 14 In the years since, at least 11 states have adopted breastfeeding-friendly childcare designation programs. 15 The Florida Breastfeeding-Friendly Childcare Initiative (BFCCI), which was created in 2012, has to-date identified 462 breastfeeding-friendly childcare centers 16 —approximately 6% of the centers in the state. Our prior work on Florida's BFCCI was designed to gauge childcare administrators' knowledge of, and interest in, becoming one of Florida's BFCCI-designated centers using an implementation framework. 17 However, our results revealed that many childcare administrators are uncomfortable with breastfeeding and regard formula feeding as normative. The purpose of this article is to explore the themes of comfort with human milk and formula feeding among childcare administrators.
Methods
Participants and procedure
A convenience sample of 28 childcare center administrators in the Tampa Bay area of Florida was recruited to participate in a semistructured interview in 2015. Study methods were approved by the University of South Florida Institutional Review Board. Childcare centers in the region (n = 190) were identified from a list of providers obtained through the Florida Department of Health, mailed study information, and called for recruitment. Eligible centers had currently enrolled infants; eligible administrators were at least 18 years old. Thirty-one administrators agreed to participate during the recruitment call, but 28 consented and completed the in-person interview. Each participant received a $50 gift card after interview completion.
Data collection
Semistructured interviews with administrators included open-ended questions, allowing for probing and follow-up questions to elicit detailed information about infant feeding practices at the center and administrators' personal feelings and perceptions. Interviews were audio recorded, transcribed verbatim, and checked for accuracy. The Consolidated Framework for Implementation Research 18 (CFIR) was a guiding framework for the interviews. Findings related to CFIR constructs are published elsewhere. 17 For the purpose of this article, key interview questions regarded the center's policies for preparation of human milk and formula, where mothers could feed infants in the center, if mothers could breastfeed without a cover in the center, administrator's perceptions of human milk feeding, and if there were written breastfeeding policies at the center (Table 1).
Interview Questions
Data analysis
Interview transcripts were analyzed using Dedoose. 19 All authors reviewed transcripts, becoming immersed in the data. Using Applied Thematic Analysis, 20 codes were created based on themes and subthemes identified from phrases that summarized major points in administrators' interviews regarding their thoughts, perceptions, and opinions of feeding human milk in a childcare setting. After one overarching theme and five subthemes were identified based on pervasiveness and importance across participants, a codebook was developed to promote uniformity of classification. Three authors (E.S., T.L., and R.-R.R.) coded the transcripts. A Kappa value of 0.8 was reached between the three coders for each code. Kappa was calculated using the Training Center application within Dedoose. 21 To help readers evaluate the extent to which conclusions from this analysis are transferrable to other childcare settings, themes are discussed using thick description in administrators' own words. 22
Results
Participant characteristics
Of the 28 participants (Table 2), all were female and had at least 6 years (range: 6–45 years) of childcare experience and 1 year (range: 1–42 years) as an administrator. Most participants were non-Hispanic white (60.7%) with a mean age of 50 years (SD = 9.8, range: 27–69 years old). The childcare centers represented the economic diversity of the Tampa Bay area with median household incomes for their census tracts ranging from $20,035 to $70,515 and 63% of the childcare centers participated in the United States Department of Agriculture (USDA) Child and Adult Care Food Program. The USDA Food Program provides reimbursement to nonprofit centers, as well as private centers with at least 25% enrollment of low-income children. 23 At the time of the study, none of the childcare centers was considered breastfeeding friendly by the state of Florida BFCCI.
Childcare Center & Administrator (Participant) Characteristics
The USDA Food Program provides reimbursement for meals and snacks provided to nonprofit childcare centers, and private childcare centers who have allotted at least 25% of their enrollment to serving low-income children. 23
The 2015 average market rate for infant childcare centers in Hillsborough County was $174 per week, and in Pinellas County, $224 per week. 38
The median household income for 2012–2016 was $51,681 for Hillsborough County and $47,090 for Pinellas County. 39
Missing = data not available.
Themes
In describing their childcare center's infant feeding policies and practices, administrators shared their thoughts, perceptions, and opinions of human milk feeding in a childcare setting. In our sample, one administrator/childcare center stood out from all the others as welcoming of breastfeeding. The overarching emergent theme from the remaining 27 interviews was “Formula feeding is normative.” Within this theme, four emergent subthemes were identified: “Human milk is potentially harmful,” “People are uncomfortable with breastfeeding in public,” “I'm not the expert,” and “‘Breastfeeding is best’, in theory” (Table 3).
Additional Quotes
Formula feeding is normative
Childcare administrators' responses regarding how their center stored and handled bottles revealed their perception that formula feeding was the normative practice. Nearly all the administrators only mentioned their policies for formula bottles and had to be asked follow-up questions about how they handled bottles containing human milk. Furthermore, over half of the time, childcare administrators interchanged “milk” for “formula” when discussing infant feeding—“it's regular milk or there's breast milk.” Most noted that they did not have formalized policies for human milk feeding at the center because they did not “have any breastfed babies here.” The perception that formula feeding was the normative way to feed babies was further revealed when administrators mentioned the following: (1) precautions taken when feeding human milk; (2) wanting mothers to use a cover when breastfeeding at the center; and (3) their discomfort providing breastfeeding support or advice to breastfeeding mothers.
Human milk is potentially harmful
A few center administrators believed exposure to human milk could be harmful to others, citing that human milk is a bodily fluid. These administrators seemed unaware that human milk is not one of the bodily fluids to which universal precautions apply.
24
Concerns about potential dangers posed by exposure to human milk led to different procedures for handling human milk versus formula. Staff in centers with these safety concerns would wear gloves while handling human milk, but not while handling formula. Two administrators took pains to ensure their staff viewed human milk as potentially harmful. For example, Isabella stated,
They know my urgency on breast milk, and I make it like it's—I make them think like I feel it's the worst thing in the world, in that it can hurt them, because in all reality, it can. And so, I tell them my high importance of if you touch it, you need to have on gloves.
While only a small number of centers took such precautions as those mentioned by Isabella, all centers took steps to ensure the separation of human milk and formula. Most notably, all centers specially labeled bottles of human milk and used separate crockpots to warm formula bottles and human milk bottles.
People are uncomfortable with breastfeeding in public
Childcare administrators overwhelmingly characterized their centers and staff as comfortable with feeding human milk and breastfeeding. Even those who considered human milk “dangerous” reported that they and their staff were comfortable with “the general idea of breastfeeding,” although they also tended to note they were only comfortable with a mother breastfeeding at the center “if she is covered.” When asked what they would do if a mother wanted to breastfeed at the center without a cover, one administrator reported “even [the center] supply[ies] her with a blanket.” If a mother wanted to feed without a cover at Libby's center, problems would occur:
Um, well, because it's, um, because it's a daycare center and we have, um, other parents coming through, uh, even children, you know, we ask them to cover, because we actually don't want children to go home and say, “Mom! We saw Miss [name's]”—you know, so, we would ask her, can you please cover because it's a daycare.
Administrators also noted that, while breastfeeding, mothers must be in the infant room and not in other areas of the center. As Maya said, “some parents will think—you know, will totally be appalled.”
I'm not the expert
Nearly all administrators expressed feeling more knowledgeable about feeding infant formula, compared to human milk. Administrators reported easily and freely giving advice to parents with formula-fed babies, such as whether to mix cereal with formula. When asked what they would do if a mother approached them with a breastfeeding question or problem, they all said they would refer that mother to her physician or pediatrician. None of the administrators indicated having breastfeeding or human milk-related materials to provide. Also, none mentioned that they would refer a mother to a lactation consultant. This hesitancy among administrators to address the non-normative feeding method they experience in their childcare center (human milk and breastfeeding) relays the message that they are only comfortable with formula, almost to say: “I am an expert in formula, but I'm not an expert in breastfeeding.” For example, Carol stated,
I did have one, uh, parent that had said that she was having a hard time breastfeeding. And, um, I simply told her maybe she should tell – talk to the doctor, to see if there's any way of implementing, uh, formula for the baby – and that we provide [brand name of formula] and, uh, she could get with the doctor to see if that would be something that we can help her with.
“Breastfeeding is best,” in theory
Nearly all administrators specified that breastfeeding was best for babies, although that was not a question asked in the interview. They noted breastfed babies were “healthier,” had a “better immune system,” were “smarter,” and that breast milk was “more nutritious than regular milk” and was “better on the stomach” (see Table 3 for more quotes). While expounding the benefits of breast milk, the administrators also noted that handling breast milk could be dangerous, and that mothers could breastfeed in the center, but only if there were restrictions on where and how. For example, Elle notes that breastfeeding makes the transition to childcare easier for babies because they have antibodies from their mothers, but she suggests women who want to breastfeed at the center turn the rocking chair toward the wall in the infant room and that these women should not “get up half naked and dance around our room.” Similarly, Jasmine stated that breast milk does not contain chemicals like formula and that breast milk is “better, healthier for the babies' growth and development,” but is only okay with breastfeeding as “long as she ain't goin’ around, walkin’ around all over the school with her breasts out.”
Overall, administrators revealed that, while breastfeeding may be best for babies, their centers regarded formula feeding as normative, as evidenced by their discomfort with breastfeeding at the centers, discomfort handling human milk, inability to address breastfeeding mother's questions, and perceptions that breastfeeding women would outlandishly flaunt their breasts. Further evidence that administrators typically perceived formula to be the normative food for babies comes from their discussion of participation in the USDA Food Program, which provides centers remuneration for feeding meals (breast milk or other foods) to children in their care. 25 Over half of the centers participated in the USDA Food Program. Interestingly, administrators noted they followed the program's guidelines for feeding infants formula, but did not mention the program's guidelines for feeding human milk, which include provisions for flexible feeding schedules and quantities for children receiving human milk. 26
Discussion
In interviews regarding infant feeding policies and practices at daycare centers, all but one of the childcare administrators revealed that formula feeding is normative, and for a few, human milk is perceived as a dangerous substance requiring extra precaution in its handling. While they acknowledged breastfeeding is the optimal food for infants, they were uncomfortable with children feeding at the breast within the center and did not know how to help or where to refer breastfeeding women who need support. Their contradictory statements highlight the perceived cultural norm of formula feeding. This cultural norm is unlikely to be overcome in these childcare settings if the centers have no enrolled infants receiving human milk. This creates a tautology whereby administrators are uncomfortable because they do not have exposure to breastfeeding, but the fact that they are uncomfortable with breastfeeding may minimize their exposure because breastfeeding mothers may be uneasy taking their infants to a center where people are uncomfortable with breastfeeding or may choose to stop breastfeeding to fit the norm.
Recognizing the importance of childcare centers in helping families meet their breastfeeding goals is a worldwide issue. 27 While breastfeeding coalitions across the United States may have developed guidance to help their local childcare programs support breastfeeding (e.g., North Carolina 28 and Florida 16 ), we could not find standard industry-wide training manuals or required modules for childcare providers that provide information on human milk feeding in a childcare setting. This suggests the larger childcare industry reinforces the cultural norm that most infants are fed formula. This norm is compounded by the larger public health and biomedical discourse around “breast is best.” For the past 40 years, among public health officials, breastfeeding researchers, and skilled lactation providers, there has been an emphasis on the benefits of breastfeeding.29–31 However, this messaging has been insufficient for achieving our nation's goals 32 for exclusive breastfeeding rates through the first 6 months of life. As mentioned, daycare administrators overwhelmingly accept that breastfeeding is best for babies, even repeating some of the most mentioned benefits. Yet administrators are not comfortable with breastfeeding and are not supportive of its practice. Thus, while we cannot specifically point to childcare as the reason women stop breastfeeding, the fact that childcare administrators are less comfortable with breastfeeding than formula feeding likely contributes to women weaning. Research is needed to explore this hypothesis.
The results of our study support the findings of Lundquist et al. 13 that childcare administrators—and likely childcare staff, as well—need education and training about breastfeeding to better support mothers. Such trainings may include education about differences in handling, storing, and feeding human milk versus formula, and, for centers participating in the USDA Food Program, information about its different regulations surrounding human milk and formula. 26 In addition, efforts to inoculate childcare providers against discomfort with the breast and the visual images of breastfeeding could be effective in normalizing breastfeeding for them. Videos explaining some of the basics of breastfeeding and showing women in the act of breastfeeding may be effective and help to debunk the myth that breastfeeding women are “running around with their clothes off” in public. Also, it is worth noting the majority of Americans (68%) support the right of women (and children) to breastfeed in public 33 ; sharing this information may help assuage fears of administrators and childcare workers.
Furthermore, we follow Lundquist et al. in their suggestion that more research needs to be done investigating and evaluating how childcare centers can help mothers meet their infant feeding goals. The findings of our study indicate that childcare administrators are uncomfortable answering mother's questions about breastfeeding and lack the resources and education to provide support. However, administrators readily provide suggestions to mothers whose children are receiving formula. While at least 11 states have “breastfeeding-friendly childcare” programs, 15 all have different qualifications for certification. Research is needed on what is meant by “breastfeeding-friendly childcare” and whether it is effective in helping mothers meet their breastfeeding goals. In addition, future research should consider what role parents would like childcare providers to play in breastfeeding support and promotion. Furthermore, research should guide and test programs to support childcare administrators and staff in effectively providing breastfeeding information, resources, and support.
Limitations
The findings of this research reflect the questions that were asked in the interview. We did not pursue the nuances of other questions regarding childcare feeding practices to the extent that we did surrounding policies related to women breastfeeding at the center. Hypothetical questions regarding what the center would do in certain situations were only asked about breastfeeding at the center, so we cannot speculate as to how administrators would have responded if we asked hypothetical questions such as how administrators would respond if a mother asked for their advice for her formula-fed child or if she wanted to feed this child at the center. In addition, the findings of this study may not be transferrable to other contexts across the United States, due, in part, to the geographic setting, breastfeeding knowledge, and cultural norms and values of childcare administrators in the Tampa Bay area. Furthermore, the sample of childcare administrators in this study was a convenience sample and may not be representative of the larger Tampa Bay childcare administrator population. This qualitative work was ideal for illustrating some of the perceptions and sentiments of childcare administrators in this area. Future work will determine the extent to which these perceptions and sentiments are representative of this and other populations.
Conclusion
The results of our study leave us considering the limitations of the “breast is best” discourse. As mentioned, childcare administrators were in overwhelming agreement with this sentiment. However, for these administrators, it did not change their perceptions about breastfeeding in public or the potential dangers of handling human milk. Human milk may be best for health, but from childcare administrators' perspectives, it may not be best for the childcare environment. While administrators acknowledge the benefits of breastfeeding, for them “breast is best” has a big asterisk next to it, namely that it is best if they do not have to see the act of breastfeeding, if they are able to feed infants without extra precautions, and if it does not mean the baby will have to be fed more often. Understanding—or acknowledging—that “breast is best” may be necessary, but is insufficient for reaching our nation's breastfeeding goals. No doubt breastfeeding initiation rates in the United States have continued to rise over the time period of the campaign, but duration rates remain far from optimal. 4 Research has shown the limitations of education alone in changing health-related behavior. 34 Indeed, while giving birth in a Baby Friendly Hospital Initiative (BFHI) 35 -certified hospital increases breastfeeding initiation, it may not translate into increased long-term continuation without community breastfeeding support.36,37 After hospital discharge, many families may be clear about “breast is best,” but likely will need support to reach the 6-month exclusive breastfeeding milestone. The moment is ripe for our communities, including childcare providers, to embrace a new message: “We can help you.”
Footnotes
Acknowledgments
The authors would like to thank the childcare centers and staff members in the Tampa Bay area for their time and participation in the study. Special acknowledgments go to Krista Schoen at the FDOH, the Tampa Bay Breastfeeding Taskforce, the Florida Breastfeeding Coalition, and Jessica Gordon for providing informational support. They also thank DeAnne Turner, Vinita Sharma, Rachel Logan, Preeti Vadlamani, Emily Rizzo, Adebukola Sangobowale, Carly Truett, Cheralynn Corsack, Tiffany Graske, Tabassum Tasnim, Laketa Entzminger, and Hanh Van Tran for their contribution in data collection and validation.
Disclosure Statement
No competing financial interests exist.
Funding Information
Funding was provided by the University of South Florida College of Public Health Individual Investigator Award.
